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THE 


Modern  Treatment  of  Wounds 


BY 


JOHIST  E.  SUMMEES,  JR,  M.D. 

S'urgeon-in- Chief  to  the  Clarhson  Memorial  Hospital;  Attending 
Surgeon  Douglas  County  Hospital.  Formerly  Professor  of  the 
Principles  and  Practice  of  Surgery  and  Clinical  Surgery, 
Omaha  Medical  College ;  Ex-President  of  the  Western  Surgical 
and  Gynecological  Association,  the  Nebraska  State  Medical 
Society,  and  the  Omaha  Medical  Society. 


MEDICAL   PUBLISHING  COMPANY, 
S15  McCague  Block,  Omaha. 

1S99. 


COPYRKiHTED.  1S99, 

BY 

J.  E.  SUMMERS,  JR.,  M.  D 


7^J>/3/ 


PRERS  OF 

STATE  JOURNAL  COMPANY, 

LINCOLN,  NEB. 


To 
JOHN  E.   SUMMERS,  M.  D., 

COLOXEL    AND    SURGEON    U.   S.    ARMY  (RETIRED) . 

A 

SMALL    TOKEN    OF    MY    AFFECTION 
AS    A    SON. 


PREFACE. 


In  the  preparation  of  this  little  book  1  have  tried  to 
indicate  means  towards  ends. 

An  attempt  has  been  made  to  keep  within  the 
subject  title  of  the  book,  yet  it  has  been  thought  neces- 
sary occasionally  to  discuss  pathology  and  diagnosis 
in  order  to  lead  up  to  a  rational  practice.  If  at  times 
some  statements  appear  dogmatic,  they  will,  I  hope, 
be  pardoned,  because  they  have  the  merit  at  least  of 
being  based  upon  a  liberal  personal  experience,  both 
as  a  teacher  and  practitioner  of  surgery. 

November  1,  1899. 


CONTENTS. 


CHAPTIOIJ   I.                                        CAGE 
Bacteria   and    VVouiuls i 

('lIA!'Ti':i;    II. 
I'reparatoi-y   Surgical   Technique 5 

CHAPTEK  IJI. 
Operative  and  Accidental  Wounds 14 

CHAPTER  IV. 
Operations  on  lul'ected  Tissues 22 

CHAPTER  V. 
Accidental   Wounds ^6 

CH.\PTET{  \1. 
Punctured  Wounds  of  the  Brain 33 

CHAPTER  VII. 
Penetrating-  Wounds  of  the  Chest 36 

CHAPTER  VIII. 
Treatment    of    Incised    and    Punctured    Wounds    of    the 

Abdomen   40 

CHAPTER  IX. 
The    Treatment    of    Intra- Abdominal    Lesions    Following 

Contusions  of  the  Abdominal  Walls 4.5 

CHAPTER  X. 
Sprains  and  Contusions  of  Joints 55 

CHx\PTER  XI. 
Compound  Wounds  of  Joints 59 

CHAPTER  XII. 
Head  Injuries 64 

CHAPTER  XIII. 
Poisoned  and  Dissection  Wounds 70 

CHAPTER  XIV. 

Specific  Woutid  Infections — Erysipelas 80 


VIU  lO.NlKMS. 

(•ii.\i"n:u  x\'.  PAGE 

Tetanus    87 

(  ii.\i'|"i:k  x\i. 

Treatment  of  Soptit-   Itlood    I'oisoning 93 

fllAl'TKi:   XVII. 
Compound  Fractiires  of  Long-  Bones l();j 

(•11.\1'T1:K   Will. 
Tre;i1ni«Mi1  <>f  ( ;  misliot   Wounds 1 IL' 

CH-M'TKIJ   XIX. 
Treatment   of  limns  and  Frost-Hites 121 

CHAPTER  XX. 
Use  of  Jvubber  (!auntlet.s  or  (Jioves 1U2 

ERRATUM. 

Page  52,  after  A'i(iue)'.—{\.)  .  .  "a  right-sided 
abdominal  section"  should  read  "a  right-  or  left-sided 
abdominal  section." 


J. 1ST  OF   PLATES. 


PLATE  I. 
"First  Aid"  use  of  elastic  tourniquet  in  crusliing  wounds 

of  the  lower  extremities Between  pages  28  and  20 

PLATE  JJ. 
A  pnnctnred  wonnd  of  the  brain  by  a  button-hook. 

Opposite  page  34 

PLATES  III  AND  IV. 

Adhesive  plaster  dressing  for  sprains  of  the  ankle-joint. 

Between  pages  58  and  59 

PLATE  V. 

Use  of  Esmarch's  tourniquet  in  operations  upon  the  skull. 

Opposite  page  69 

PLATES  YI,  VII,  AND  VIII. 
The  making  of  a  window  in  a  j)laster  of  Paris  splint. 

Between  pages  lOS  and  109 

PLATE  IX. 
Extensive   burn   under   process    of   repair   by    Thiersch's 

method  of  skin  grafting Opposite  page  126 


MODEPtN  TEEATxMENT  i)V  \V(JUAJJ.S. 


CHAPTER  I. 

BACTElllA  AND   VVOLF.NDS. 

Effect  of  Bacteria  on  Wound  Hcaliny. — The  most  im- 
portant principles  nnderljing  the  treatment  of  wounds 
are  based  upon  a  clinical  comprehension  oi'  bacteri- 
ology, however  desirable  it  may  be  lor  the  practitioner 
to  have  a  combined  laboratory  and  bedside  knowl- 
edge. It  should  be  well  understood  that  the  intro- 
duction of  micro-organisms  into  wounds  is  responsible 
for  most  ill  eti'ects,  except  those  due  directly  to  the 
nature  of  the  wound.  This  introduction  of  micro- 
organisms into  wounds  can,  in  those  inflicted  by  the 
surgeon,  be  prevented,  and  in  the  treatment  of  all 
wounds  means  are  at  command  to  nullify  or  modify 
any  serious  results  caused  by  micro-organisms. 

The  marvelous  decrease  in  death  rate  from  wounds, 
either  surgically  or  accidentally  inflicted,  and  the  lim- 
itations of  the  spread  of  infectious  diseases,  are  all  the 
result  of  the  work  of  laborers  in  the  field  of  bacteri- 
ology and  experimental  medicine.  Among  the  numer- 
ous germs  we  need  onlj^  consider  the  chief  ones  acting 
as  etiological  factors  of  surgical  wound  diseases. 

Divisions  of  }Iicro-orf/anisms. — There  are  three  chief 
divisions  of  micro-organisms  which  we  have  to  bear  in 
mind:  1.  Micrococci,  which  are  cells,  either  round  or 
oval  in  form,  and  may  be  found  singly,  in  chains,  or  in 
masses.  2.  The  Bacilli,  which  are  rod-shaped  cells, 
found  singly,  in  chains,  or  swarms;  their  length  is 
more  than  twice  their  breadth.  3.  Bacteria,  which 
may  be  rod-shaped,  but  when  so  their  length  does  not 
more  than  equal  twice  their  breadth;  they  are  also 
oval  in  fo-rm,  and  are  found  single,  in  chains,  or 
masses.  All  the  different  forms  of  micro-organisms 
are    quite    commonly    spoken    of    under    the    general 

(1) 


-  Ml>lH:i:.\     lUKATMICNT    Ol'    \\\)UNUS. 

lu'atliuy:  oI"  liurlrr'm.  Thev  all  liavi'  ilic  properly  ol'  a 
uiarvc'lous  loprotiiicliDU,  luillions  liciiiy;  jjt'iu*ratt'd 
ii-oin  a  sin«;l(*  liaiilhis  in  a  lew  hmiis.  All  bacicriii 
art'  of  \c^eiaL)li*  <n-ij,Mii. 

Many  haclcria  arr  capalilc  oT  protimin^  iirilatiou 
and  iiilianmiation  (»f  wdunds.  Tlu'y  aci  cillu-i'  di- 
rcilly  or  by  cluMnical  pi-o<.lu<ts  idinicd  as  a  result  of 
their  known  pcpionizin^  action  upon  (lu*  albuminous 
substances.  These  aie  j»ouied  out  upon  the  wound 
area  and  are  intended  by  nature  as  reparative  ma- 
terial. This  peptoniziujjj  action  results  in  the  produc- 
tion of  what  is  called  pus.  The  so-called  pyogenic 
([)Us-forminjji;)  organisms  are  chielly  responsible  for  this 
peptonizing  action,  confined  at  first  to  the  surface  of 
the  wound,  but  later  penetrating  into  the  tissues  them- 
selves. In  some  cases  either  bacteria  or  their  chemi- 
cal products  i)enetrate  into  the  deeper  lis>>ies  of  the 
wound  or  enter  the  general  circulation, producing  more 
extensive  local  irritation  or  severe  intoxiraliou.  Or 
dinaiily,  the  only  organisms  (cocci)  which  cause  the 
fornuition  of  i)us  are  the  staphylococcus  jtyogenes  au- 
reus and  albus  (which  form  in  clusters)  and  another 
much  more  dangerous  organism,  the  streptococcus  py- 
ogenes (cocci  which  form  in  chains).  The  Tetanus 
Bacillus  is  also  of  importance.  When,  as  is  a  common 
occurrence,  wounds  which  have  been  (^xposed  to  micro- 
organism infection  heal  without  the  formation  of  pus 
we  know  that  either  something  prevented  the  pepton- 
izing action  of  these  organisms  upon  the  albuminous 
elements  of  the  wound  secretion  (exudate),  or  that  na- 
ture was  ab]<'  in  the  struggle  for  supremacy  ilhc  battle 
between  the  organisms  and  the  vital  elements  of  the 
body)  to  conqu(M-.  Bacteria  usually  grow  rapidly  at 
a  temperature  ranging  from  7.")°  to  104°  F.  Those 
which  grow  at  the  lower  temiierature  tend  to  cause 
a  i)utrefactive  condition  in  the  wound  secretion;  those 
which  grow  most  rajudly  at  the  higher  temperatures 
are  commonly  those  producing  diseases  of  a  more  or 
less  typical  kind  and  are  called  iidtJiof/oiic.  The  his- 
tory of  e]>idemic  diseases  lias  pi-oven  that  severe  cold 
does  not  kill  many  lta<teiia.  the  disease  rea])y)eai'ing 


I'.AC'I'IOHIA    AM)    VV()i;,\l>S.  3 

upon  (he  id  mil  (tl'  ilic  \v;iiiii  .sciJHon.  Dry  Ik-jiI  is  uof 
a  reliable  a^cnl  lo  kill  iiiici'o-or^anisiriH,  but.  tiioiHl 
liejil,  boiliiii;  wnlci-  oi*  sleain,  because  of  its  greater 
penetration,  will  kill  every  variety  of  bacteria.  Many 
chemicals  have  the  power  of  killing  bacteria  and  at 
the  same  time,  w  lien  usihI  jurticiously,  do  not  act  in  a 
hainifiil  way  upon  wouvids.  A  utilization  of  o>ir 
kiu>wle(l^(*  of  the  action  of  both  lieat  and  these  chenii- 
cals  upon  all  micro-organisms  is  the  basis  upon  which 
is  built  the  modern  treatment  of  woun,ds, — the  Aseptic 
and  Antiseptic  Methods. 

Aseptic  ^^i(r(/crt/. — By  Aseptic  Surgery  is  understood 
the  employment  of  known  means  (chemical  and  me- 
chanical) in  tlie  sterilization  of  the  hands  of  opera- 
tors and  assistants,  instruments,  and  all  dressings  and 
material  used.  The  sterilization  of  the  tissue  area  of 
the  wound  about  to  be  made  must  also  be  complete 
and  the  wound  protected  from  contamination  from  all 
sources.  After  the  incision  or  puncture  no  chemical 
agents  having  irritating  or  sterilizing  properties  are 
allowed  to  come  in  contact  with  the  raw  surfaces. 
The  dressings  applied  must  be  sterile,  but  contain  no 
chemical. 

Antiseptic  Surgery. — Antiseptic  Surgery  is  the  em- 
bodiment of  all  the  details  of  Aseptic  Surgery  and 
in  addition  the  use  of  chemicals  upon  the  wound  sur- 
faces during  the  progress  and  after  the  completion  of 
the  operation.  The  idea  being  to  inhibit  by  the  use  of 
chemicals  the  possible  ravages  of  bacteria  which  may 
have  gained  entrance  into  the  wound  because  of  a 
faulty  technique  or  preparation  upon  the  part  of  those 
concerned  in  the  carrying  out  of  the  operation.  With 
few  exceptions  all  wounds  not  made  by  the  surgeon 
demand  antiseptic  treatment.  The  employment  of 
certain  chemicals  (antiseptics)  is  intended  to  kill  or  to 
weaken  the  power  of  any  germs  which  possibly  have 
infected  a  fresh  wound.  If  suppuration  is  already 
established  these  chemicals  stop  fermentation  and 
putrefaction,  and  i)rotect  the  patient  from  the  more 
severe  local  and  constitutional  effects  of  wound  infec- 
tion. 


•4  MOPKUN     IKKArMKNT    OP    WOINDS. 

Drdlmufv. — Another  cardinal  piiiK-ii»al  »»t  antiseptic 
suijit^ry  is  to  ]ir()\i(l('  for  iliaina<j;o  in  wounds  where 
th«M'e  is  supiMii-ii  ion,  and  to  so  care  for  theso  wounds 
that  ail  disclniij^cs  will  be  i-c*ct'ivt'd  into  drcssinj^s 
inii>i't*<;i:nated  witli  antiseptirs  which  will  int'vcnt  ])n- 
trefaction  of  discharges.  Antiseptic  dressings  arc  also 
«Mni>loyed  to  k(M-p  ficrnis  from  ^ainint::  access  lo  a 
wi>un(l  aflci-  the  coniidction  of  an  oix'ialion,  or  to  jnc- 
vi'ut  reinfection  of  a  disinfected  wonnd. 


PBErAUATOIlY    SUI{<iI<JAJ.    I'KCJJXKAlJB.  •) 

(JlIArTEK  11. 
PREFAKATOllY  SURGICAL  TECHNIQUE. 

Disinfection  of  the  Hands  and  Forearms  of  the  Huryvuii. 
— This  must  be  both  mechanical  and  chemical.  The 
surgeon  and  jiHsislaiil  whoiild  (hoi-ouglily  scrub  liicir 
bauds  aud  i'orearms  with  warm  water  aud  soap,  beiug 
particularly  careful  to  remove  all  dirt  and  macerated 
epithelium  from  around  and  under  the  finger  nails, 
using-  the  scrub  brush  and  nail  cleaner  carefully. 
Both  the  brush  and  nail  cleaner  ought  to  be  boiled  in 
ordinary  water  or  immersed  in  a  5  per  cent,  solution 
of  carbolic  acid  in  water  before  using.  After  this  me- 
chanical cleansing,  wash  the  hands  and  forearms  in 
sterilized  warm  water,  and  in  addition  have  a  little 
alcohol  poured  on  the  hands.  Then  immerse  the  hands 
and  forearms  in  a  1-1,000  solution  of  bichloride.  Green 
soap  is  preferable  to  other  soaps,  and  especially  is  this 
so  when  a  little  corn  meal  has  been  added  to  it.  Green 
(soft)  soap  and  turpentine,  with  liberal  quantities  of 
ordinary  warm  water,  a  good  nail  brush  and  nail 
cleaner  can  render  the  hands  proof  against  infecting 
a  wound.  Because  of  its  efficacy  and  the  smooth  con- 
dition in  w^hich  the  hands  are  left  the  following  way 
of  sterilizing  the  hands  is  practiced  by  many:  After 
thoroughly  washing  the  hands  and  forearms  with 
soap  and  water  and  a  brush  and  using  the  nail  cleaner, 
a  tablespoonful  of  chlorinated  lime  is  placed  in  the 
palms  of  the  hands  and  to  this  is  added  an  equal  quan- 
tity of  washing  soda  (carbonate  of  soda).  When  suf- 
ficiently moistened  and  mixed  by  rubbing  the  hands 
together  the  mixture  is  made  to  come  in  contact  with 
all  parts  of  the  forearms  and  hands,  especially  around 
the  nails.  Hot  sterile  water  is  used  to  wash  away  the 
mixture.  Any  method  of  sterilization  of  the  hands 
must  be  conscientiously  carried  out,  and  the  simple 
ones  given  are  as  reliable  and  more  easy  of  accom- 
plishment than  many  others.  The  practical  and  ideal 
way  of  protecting  a  wound  against  infection  is  the 


<»  M(ilii:i:.\     lUI^AT.MKNT    UI"    WdlNDS. 

Iiabiiiial  use  ol'  si t'l'ilizfil  nililM-i-  ^hixcs  l)\  cvcrvoiu' 
lakiu^-  pari  in  a  suruical  ojk  rai  imi.  1)1'  this  we  will 
sjii*ak  laUM-. 

SlcriUztiHuii  nf  Li(/uliiii.s  and  Sni uriii;/  Mali  rials. — 
Silk  which  has  beeu  boik'd  loi*  oiu*-hall'  hour  Ix-lorc 
an  tipi'ialioii  is  practitally  safe,  but  il  uiav  lie  math' 
aud  pivsei'ved  sterile  by  boiling  in  water  for  ((iic  h<»\ii" 
and  Ihen  i)Iai-ing  it  in  a  .">  per  i-enl.  carbolic  acid  sola 
tion,  made  by  adding  the  acid  to  freshly  boiled  water. 

Silh-ivunii  (Jut  and  i^ilrcr  Wire. — These  are  best  ster- 
ilized by  boiling  in  water  from  fifteen  minutes  to  half 
an  hour  immediately  before  using.  Souie  surgeons, 
however,  consider  the  immersion  of  these  materials  in 
a  o  i)er  cent,  solution  of  carbolic  acid  in  water  suf- 
ficient for  their  j)ractical  sterilization. 

Catiiut. — The  most  modern  method  for  the  sterili- 
zation of  catgut  is  by  means  of  formalin,  the  advantage 
being  that  the  gut  is  rendered  less  soluble  in  the 
tissues  aud  therefore  more  reliable.  After  the  gut 
has  been  impregnatc'd  with  formalin  it  can  also  be 
subjected  to  boiling  in  water  without  losing  its  tensile 
strength.  The  gut  is  first  immersed  in  a  solution  of 
formalin  of  from  2  to  4  per  cent.,  according  to  its  size, 
and  allowed  to  remain  in  the  solution  for  a  period  of 
from  twelve  to  forty-eight  hours.  The  formalin  is 
then  removed  by  soaking  in  cleai'  water  for  twelve 
hours,  the  water  being  changed  frequently.  It  is  then 
boiled  in  water  for  fifteen  minutes,  after  which  it  is 
transferred  to  a  vessel  containing  alcohol,  whei'e  it 
may  be  kept  until  reo.uired  for  use.  From  2  to  4  per 
cent,  of  carbolic  acid  may  be  added  to  the  alcohol,  as 
it  makes  the  gut  more  firm.  It  should  be  i)laced  in 
plain  alcohol  for  about  a  half  hour  before  using.  Be- 
fore boiling  the  gut.  it  should  be  wound  tightly  on  a 
glass  spool  or  di'y  cork,  the  object  being  to  keep  the 
gut  in  a  high  state  of  tension.  The  coi-k  has  sonn' 
advantages  over  the  glass  rod.  in  that  it  ex])ands  by 
the  absorption  of  the  water,  and  thus  increases  the 
tension  on  the  gut. 

One  of  the  best  methods  foi'  (lie  slciili/at ion  of  cat- 
gut tcifhont  the  use  of  formalin   is  the  following:    .\ 


I'UiiM'AitA'i'oKV  .si!i{i;i<  Ai,  ■ri;<ii.\i<.ti  r:.  < 

reliable  ai-lich;  <»r  calf^til  in  (lillVicDl  Hi/.cs  should  he 
wound  and  twisted  into  loose?  rings  about  three  foiirtliH 
of  an  inch  in  diaine(<!i'.  'J'hese  are  placed  in  a  1-1,000 
solution  oi"  bicliloride  ether,  remaining  for  twenty- 
four  hours,  t^ie  ether  abstra<-ts  the  fat  from  the  gut. 
ii  is  then  removed  and  placed  in  l)icliloi'ide  alcohol, 
1-1,000,  for  twenty-four  houi-s.  The  got  is  then  put 
into  alcohol,  and  the  bottle,  a  wide  mouthed  one, 
lightly  stopped  with  sterile  absorbent  cotton,  i>laced  in 
a  vessel  of  boiling  water  and  boiled  for  fifteen  minutes. 
This  boiling  is  repeated  for  three  successive  days,  add- 
ing sufficient  alcohol  when  too  much  evaporates. 
After  the  third  boiling  the  gut  is  placed  in  absolute 
alcohol  and  is  ready  for  use.  When  required  it  must 
be  removed  from  the  bottle  with  sterilized  forceps. 
If  thought  best  to  chromicise  this  catgut,  in  order  to 
add  to  its  strength  and  resistance  to  rapid  absorption, 
it  is  placed  into  this  solution:  Chromic  acid  1  part; 
carbolic  acid  200  ])arts;  sterile  water  2,000  parts. 
After  twenty-four  hours  the  gut  is  removed  and  placed 
in  absolute  alcohol.  Bichloride  of  mercury  should  not 
be  added  to  the  preserving  alcohol,  as  it  renders  the 
gut  too  brittle. 

Gatyut  as  Prepared  and  Hold  hij  ^Supplij  Houses. — 
It  is  becoming  the  custom  among  surgeons,  and,  in 
fact,  of  some  hospitals  of  best  repute,  to  buy  catgut 
all  ready  prepared.  The  only  articles,  however,  which 
are  reliable  are  those  which  are  prepared  in  hermeti- 
cally sealed  glass  tubes,  requiring  the  breaking  of 
these  for  their  use.  Complex  arrangements  furnished 
by  the  supply  houses  which  admit  of  catgut  and  silk 
being  pulled  out  in  shorter  or  greater  lengths  are  dan- 
gerous and  should  be  avoided,  as  the  material  remain- 
ing in  the  bottles  may  become  contaminated  from 
without.  For  the  ordinary  minor  surgery  of  the  of- 
fice and  private  family,  needles  of  dilTerent  sizes 
and  curves,  already  threaded  with  silk,  silkworm 
gut,  or  catgut,  sterilized  and  sealed  in  glass  tubes,  as 
furnished  by  the  supply  houses,  are  convenient  and 
thoroughly  reliable. 
2 


8  MODERN    TREATMENT    OF    WuLNDS/ 

KaiKjaroo  'J'citdon. — Fur  buried  absoibalik'  suluios 
iu  ctrtiiiu  opei-atious,  especially  for  llie  radical  cure 
of  hernia,  there  is  perhaps  uo  material  equal  to  kan- 
garoo tendon.  For  its  use  we  are  indebted  to  Marcy, 
of  Boston,  and  from  him  the  best  article,  either  ster- 
ilized or  non-sterilized,  is  to  be  procured.  The  steril- 
ized article  is  expensive.  However,  a  large  bundle  of 
the  tendons  can  be  bought  for  a  moderate  sum  and 
sterilized  at  home.  The  following  is  the  method  used 
and  advised  by  ^larcy:  The  tendons  are  lirst  soaked 
in  a  solution  of  1-1,000  of  bichloride  of  mercury  in 
water  until  supple.  They  are  then  carefully  separated 
and  dried  between  sterilized  towels.  After  assorting 
them  into  small  bundles,  Ihey  are  chromicised  by  plac- 
ing them  in  a  1-20  watery  solution  of  carbolic  acid  to 
which  has  been  added  1-4,000  part  of  purified  chromic 
acid.  The  tendons  must  be  immersed  in  the  solution 
immediately  upon  Ihe  ])reparation  of  the  fluid,  since 
otherwise  in  a  short  period  the  chromic  acid  is  thrown 
down  as  a  sedimentary  deposit. 

The  process  of  chromicization  goes  on  more  or  less 
rapidly,  dependent  upon  heat,  exposure  to  sunlight, 
the  quantity  of  material  manipulated,  and  requires 
careful  watching,  since,  if  too  rai)idly  effected  or  per- 
mitted to  remain  too  long  in  the  solution,  the  tendons 
may  bo  easily  ruined.  When  properly  chromicised, 
the  tendons  should  be  of  a  dark  golden  color.  When 
taken  from  the  chromicizing  fluid  the  tendons  are 
best  dried  in  the  sunshine  between  sterilized  towels, 
and  should  be  immediately  put  in  a  carbolic  oil,  the 
whole  process  carefully  conducted  under  aseptic  con- 
ditions, tlie  bottles  securely  corked  and  sealed.  When 
wanted  for  use,  the  tendon  is  carefully  taken  from 
the  bottle,  soaked  in  a  mercuric  solution  until  supple, 
!ind  then  arranged  in  jtnrallel  strands,  wi'ap])ed  in  a 
folded  towel  saturated  with  a  1  to  1,000  mercuric  solu- 
tion, the  ends  of  the  tendons  exposed  so  that  they  may 
be  withdrawn  one  ;it  a  time  as  selected.  If  more  con- 
venient. 1h(\v  can  i-emain  immersed  in  a  dish  of  bi- 
chloride solution  dui'ing  the  operation  and  selected 
as  required.     The  ;n;ionnt  of  the  l)ichl<tride  cfsnlained 


riuoi'AKA'roiiY  .siJit(;i(JAi>  TioonNiQUE,  :3 

ill  ihe  suture  doew  no  liunu  Lo  Liie  sUu(;Lui(%s  in  wiiicii 
it  is  buried;  it  is  advantageous  rather  than  otherwiHe, 
Many  surgeons  deem  it  uniuicessai-y  to  do  more  than 
phice  tlie  tendons  into  bichloride  etiier,  1  to  1,000,  lor 
twelve  hours,  and  then  remove  them  and  i>iace  them, 
strung  out,  into  a  long  narrow  bottle  lilled  with  alco- 
hol. For  use  they  are  removed  as  reciuired  and  put 
into  a  1-40  solution  of  carbolic  acid  in  water. 

Dressings  and  Instruments. — All  materials  used  lor 
covering  and  protecting  wounds  should  be  prepared 
and  handled  with  the  most  scrupulous  care.  Dry 
sterile  dressings  are  best  used  to  protect  wounds  either 
aseptically  or  antiseptically  made,  from  which  little 
or  no  discharge  is  expected.  All  other  wounds  are 
more  safely  handled  by  being  covered  with  dressings 
which  are  moist  with  some  antiseptic  iluid.  If  a  dry 
dressing  is  employed  to  cover  a  wound  which  may  jjos- 
sibly  have  become  infected  or  is  discharging  pus  at 
the  time  the  dressing  is  applied,  there  will  always  be  a 
greater  or  less  accumulation  of  discharges  under  the 
dressing,  just  as  pus  is  retained  under  a  scab.  Such 
a  condition  cannot  help  but  interfere  with  the  repara- 
tive process.  Gauze  (cheese-cloth)  is  the  material  usu- 
ally used  next  the  wound  surface.  Absorbent  cotton 
is  placed  over  the  gauze,  and  over  all  a  bandage  or 
binder.  One  or  two  layers  of  gauze  or  cotton  may  be 
fastened  over  a  dry  wound  by  means  of  sterile  collo- 
dion applied  to  the  borders  of  the  dressing.  Gauze 
may  be  impregnated  with  some  antiseptic  material, 
as  iodoform  or  boracic  acid,  or  either  these  or  some 
other  drug  in  powder  form  can  be  dusted  upon  the 
wound  before  the  gauze  is  applied. 

Gheese-clofh  may  be  bought  from  the  dry  goods 
houses  at  from  2-|  to  4  cents  per  yard.  To  prepare  for 
use,  boil  for  fifteen  minutes  in  a  solution  of  carbonate 
of  soda,  1  dram  to  1  o.uart  of  water,  and  then  for  one- 
half  hour  in  clear  water;  cut  into  sized  pieces  desired 
and  put  into  an  Arnold  or  Boeckmann  sterilizer  for 
one  hour  before  using.  It  is  desirable  in  transporting 
gauze  after  sterilization  to  put  it  in  some  sterilized 
glass  vessel  or  iar. 


10  MOKKUN     TKKATMKNT    OK    WcH'NDS. 

lodoroiiii  j^aiizr  iiiav  ln'  ilius  itrc}»ai"ed: 
Siilt  solution  soiipsiuls  .  11  5 

loclolnrin  jK)\vtU'r  I"  5 

Sterili/inl  g'ati/.c  .  .  .      .">  yards. 

Mix  thoroujj^lily.  Kiil>  ilic  solution  \\r\\  imu  tho 
nu'sbes  and  whou  tii(»r«)U}^lil_\  iiupiciinalcd.  loU  loosely 
and  keej)  in  colored  y:lass  jars. 

^^'o  prepare  sterile  ctdlodinn  in  this  way: 
Ether  (Squihh's), 

Aleoliol  (absolute),  .  .        aa  5  viss. 

To  this  add  ///  xvi  of  a  s(t!ulion  made  by  dissolving 
gr.  XV  of  bichloride  of  mercury  crystals  in  absolute 
alcohol  ,')  xi.  Then  add  of  "Anthony's  snowy  cotton"' 
sufficient  to  make  a  syru]». 

!<tcrHizi IS. — Every  surgeon  should  own  some  kind  of 
sterilizer,  the  simi)lest,  best,  and  cheapest  being  the 
Hoecknumn  or  Arnold.  In  one  of  these  the  instru- 
utents,  silk,  or  silkworm  gut,  together  with  towels, 
ajirons,  gauze  for  sponging  and  dressings,  may  he  ster- 
ilized at  the  patient's  home  during  the  hour  ])receding 
the  ojjeration.  On  a  pinch,  gauze  or  other  material  to 
be  used  as  a  dressing  can  be  boiled  in  any  vessel  or 
saturated  with  some  antiseptic  solution,  as  carbolic 
acid  1  to  20  in  water,  or  bichloride  1  to  500.  After  the 
soaking  the  gauze  had  better  be  transferred  to  weaker 
solutions  before  being  wrung  out  for  use.  It  is  best 
to  keep  at  hand  moist  antiseptic  gauzes  from  reliable 
houses.  These  gauzes  are  more  convenient,  safe,  and 
economical  if  bought  in  one  yard  packages.  The  con- 
linued  reopening  of  the  ti\-e-yai'd  packages  leads  to 
danger  of  infection;  besides,  they  are  bulky.  Very 
little  gauze  or  cotton  is  needed  in  any  freshly  made 
wounds  unless  oozing  is  antici])ated  or  drainage  pro- 
Aided  foi'.  A  light  gauze  or  cotton  collodion  dressing 
is  j)referable. 

TnstrumcniH  can  be  sterilized  by  boiling  in  any  kind 
of  a  receptacle;  those  made  especially  for  the  purpose 
are  most  convenient.  To  pi-event  rusting  and  to 
raise  the  boiling  point  of  the  water,  add  carl)onate  of 
soda    in    tin*  piopoition   of  one  tablespoonful   to  the 


I'KIOI'AltA'IOIlN     SliltCJICAl-     I  101   IIMQUK,  |  1. 

(liiarl.  IC  iii.slnmu'jilH  aie  cai'cfull.y  scnihbcd  witli 
gieoii  soap,  (iiipenlinc,  and  wann  walci-,  washed  oil 
with  oi'diiiary  clean  water  und  placed  inio  a  I  to  lio 
soluliou  of  cai'bolie  acid  in  walei-  loi-  hall'  an  honi'. 
and  then  h'aiisfei-i'ed  to  a  weaker  solution  just  Im  loic 
the  operation  is  (o  be;;iii,  (hey  <aii  Ix-  i-(-licd  ii|i(»ji  //■;/ 
to  iuL'eet  a  wound. 

l^pon<jC8. — Sterilized  <j;auz('  cui  iiiio  suitably  sized 
pieces  is  now  most  often  used  loi;  sponj^ing  wounds. 
Sea  sponj^-es,  it  properly  prepared,  are  safe  and  better 
than  any  other  material  for  sponging-.  All  loose  sand 
should  be  beaten  out  of  the  sponges.  After  this  they 
are  put  in  water,  sharply  acidulated  with  muriatic 
acid,  and  allowed  to  remain  twelve  hours.  This  will 
dissolve  out  all  of  the  lime  salts  they  contain.  The 
sponges  are  then  washed  in  clear  water  and  put  into  a 
1-20  solution  of  carbolic  acid  in  water.  In  twelve 
hours  they  are  ready  for  use. 

Opera  ting  Outfit. — It  is  good  practice  to  have  one's 
outfit  for  a  proposed  operation  sterilized  at  home  be- 
fore leaving  for  the  place  of  operation.  Instruments 
are  boiled,  wiped  dry  with  a  sterilized  towel,  and 
placed  in  a  sterilized  canvas  roll ;  in  this  roll  are  put 
needles,  silk,  and  silkworm  gut  wrapped  in  a  piece  of 
sterile  gauze.  The  roll  is  then  pinned  up  in  sterilized 
towels.  Drainage  tubes  (glass  and  rubber),  nail 
brushes,  towels,  operating  gowns  (always  three  or 
four  for  use  of  assistants),  bandages,  gauze,  and  cot- 
ton, after  sterilization  in  a  Boeckmann  sterilizer,  are 
similarly  wrapped  up.  Instrument  trays  are  likewise 
sterilized  and  protected.  A  cheap  canvas  ''telescope"' 
of  medium  size  will  hold  the  necessities  for  any  sur- 
gical operation.  Everything  can  be  carried  in  one  of 
them,  except  anesthetizing  outfit,  jar  of  iodoform 
gauze,  sterile  collodion,  iodoform,  and  boric  acid  in 
dusting  bottles,  turpentine  and  alcohol,  bichloride  tab- 
lets, soap  mixture,  antiseptic  silk,  and  catgut.  These 
are  put  in  the  surgeon's  bag. 

Operations  in  Private  Dwellings. — When  an  opera- 
tion is  to  be  done  in  a  private  dwelling,  the  best 
lighted  room  is  selected  in  which  to  operate,  draperies 


ll'  MODEUN    TREATMKNT    OF    WOINUS. 

are  ieinoved  as  well  as  all  light  ruiuiiuiej  liie  wood- 
work aroimd  the  windows  aud  doors  is  goue  over  with 
daiiii>  towels.  If  there  is  uo  carpet  on  the  iloor,  this 
should  be  mopped.  .\i though  it  is  preieiable  to  take 
up  a  earpet  from  the  tioor  of  u  room  to  be  used  as  au 
operating  rot)ni,  it  is  not  essential,  as  the  carpet  may 
be  s])rinkled  with  water,  and  that  part  unOer  aud 
around  ihe  operating  table  protected  with  sneets. 
There  should  be  no  dusting  or  sweeping.  A  visit  to 
the  kitchen  aud  other  rooms  will  result  in  the  finding 
of  an  operating  table,  either  long  enough  for  the  case 
in  hand,  or  it  may  be  made  so  by  placing  a  small  table 
at  either  end  to  suppoit  the  head  or  feet;  in  lieu  of 
the  small  table,  a  box  rested  upon  a  chair  does  very 
well.  In  most  cases  a  table  suHiciently  long  to  sup- 
port the  head,  trunk,  and  lower  extremities  as  far 
as  the  flexure  of  the  knees  will  do.  A  short  kitchen 
table  can  usually  be  lengthened  as  described  so  as  to 
answer  the  purposes  of  au  operating  table  better  than 
can  the  usual  extension  dining-room  table,  which  is 
too  wide  for  efficient  aid  from  an  assistant  when,  per- 
haps, it  may  be  most  needed.  When  the  Trendelen- 
burg posture  is  required  and  the  surgeon  has  not  at 
hand  a  Krug  frame,  or  some  similar  contrivance,  the 
difficulty  is  easily  overcome  by  tightly  pinning  a  folded 
sheet  or  blanket  around  the  four  legs  of  a  stiff-backed 
chair,  the  sheet  or  blanket  being  so  fastened  that  it 
covers  well  the  bottom  of  the  chair  legs.  When  the 
chair  is  placed  upon  the  table  in  the  position  of  a  ''bed- 
rest" it  makes  a  frame  upon  which,  with  the  legs  hang- 
ing over  the  pinned  sheet  or  blanket,  a  Trendelenburg 
position  of  from  40°  to  45°  is  obtained. 

One  table  is  selected  upon  which  to  ]dace  iusti-u- 
ments;  another  for  dressing  and  sponging  material. 
Most  any  piece  of  furniture  having  a  flat  top  will  do 
(juite  as  well  as  a  table  for  these  purposes.  Chairs 
should  be  placed  convenient  to  both  the  operator  and 
bis  assistant,  upon  wb.ich  may  be  placed  bowls  to  con- 
tain boiled  water  or  antiseptic  solutions  in  which 
their  hands  may  be  dipped  from  time  to  time.  The  an- 
esthelizei-  should  receive  the  consideration  of  a  chair. 


ritJoi'AiiA'roiiv:  ,suJt<;jUAL  teghmquio.  13 

111  the  liouses  oT  llio  very  poor,  one  or  two  cliair.s,  u 
box,  and  even  the  llooi-  may  be  made  to  answer  all  iie- 
cessiLie.s. 

Dismfcction  of  the  t^lcin  of  I  lie  J'allcnt. — VVlieu  Lbe 
nature  of  the  ease  allows  two  or  three  days  prepara- 
tory (reatment,  the  })atient  should  be  given  Houui  in- 
ternal medication  to  stimulate  the  physiological  func- 
tions of  the  skin,  and  also  one  or  two  immersion  or 
sponge  baths.  During  the  baths  sjjecial  fjains  must 
be  taken  to  thoroughly  cleanse  the  area  of  a  proposed 
operation  wound.  Especially  ought  this  to  be  insisted 
upon  when  either  the  feet,  umbilicus,  or  hairy  parts  of 
the  body  are  within  the  field  of  a  proposed  operation. 

On  the  morning  of  the  day  of  operation,  or  the  even- 
ing before,  the  skin  immediately  over  and  for  a  rea- 
sonable distance  around  the  site  of  the  operation  must 
be  scrubbed  with  soap  and  water,  shaved,  and  then 
washed  with  ether  or  alcohol.  It  should  then  be 
covered  with  towels  or  pieces  of  clean  muslin  or 
cheese-cloth  which  have  been  saturated  in  and  then 
partially  rinsed  out  of  a  solution  of  bichloride,  1-1,000. 
It  is  well  to  cover  this  with  florist's  oiled  paper  or 
some  other  impervious  material,  as  rubber  tissue  or 
oiled  silk,  which  has  also  been  washed  in  a  bichloride 
solution.    Over  all  apply  a  bandage. 


14  MODEUN     riM'.Ar.MKNr    t)l"    WtU  NHS. 


CllAl'TKK  111. 
OPEKATIVE   AM)  ACCIDKN  TA  l>   WOINDS. 

Ojxnitivc  (1)1(1  Accidental  Wounds. — WOmuls  may  be 
convenienlly  classified  intd  those  made  by  the  sur- 
geon aud  those  not  made  by  the  surgeon.  In  the  first 
class,  when  the  nature  of  the  wound  from  its  bottom  to 
surface  is  through  non-infected  tissue,  the  rei)arativ<i 
process  ought  to  be  conducted  so  as  to  have  union,  if 
desired,  by  first  intention;  or,  if  by  granulation,  the 
wound  secretion  should  be  free  from  pus-producing 
germs.  An  attempt  should  be  made  to  bring  about 
the  same  ivsults  in  wounds  of  class  1',  whenever  they 
can  be  brought  under  treatment  sufliciently  early. 
All  wounds  of  class  1  or  2  which  are  infected  primarily 
or  secondarily  heal  by  granulation,  with  the  fonua- 
tion  of  pus.  Most  wounds  made  by  the  surgeon's  knife, 
when  directed  through  healthy  tissue,  as  for  example, 
for  the  removal  of  a  liponui  from  the  thigh,  can  be 
managed  so  as  to  heal  by  pi-imary  union,  or  by  blood 
clot.  Great  care,  however,  must  be  taken  to  place  the 
wound  at  rest.  liy  rest  is  meant  the  removal  or  pre- 
vention of  all  irritations,  chemical  or  mechanical, 
which  are  known  to  inhibit  the  healing  of  wounds. 
Irrigating  fluids,  if  used  at  all,  must  be  bland. 

Tn}(/ation  (ind  Clcansiii;/  of  Fresh  Wounds-. — Noth- 
ing answers  so  well  as  the  normal  salt  solution  when 
the  surgeon  is  reasonably  certain  that  he  has  been 
able  to  safely  carry  out  asepsis.  If  any  doubt  exists 
in  his  mind  as  to  this  most  important  point,  the  ben- 
efit to  be  expected  from  the  use  of  antiseptii;  irri- 
gating fluids,  as  carbolic  acid  1-40,  1-20,  or  corrosive 
sublimate  1-4,000  to  1-500,  are  immeasurably  greater 
than  any  bad  effei't  they  may  have  on  the  reparative 
proc(^ss.  Carbolic  acid,  corrosive  sublimate,  and  all 
other  chemicals  having  the  power  to  kill  germs  or 
render  them  inert  also  have  the  pro])erty,  when  ap- 
plied to  fresh,  raw  surfaces,  of  causing  a  more  or  less 
profuse   t'xndation   of   lymph    fiom    the    blood-vessels 


OI'IOItATIVIO    ANI>    A<;(II)|.:.\  TAI.    WOUNDS.  15 

and  lliis  unne<"('HHai'y  a.mouiil  oi'  lymph  actH  niccliajiJc- 
ally  ill  prevcnliiif;-  aooniate  ajiijroxijnation  of  raw  mir- 
faccs  one  (o  anollici'.  IJcsidtts  an  amount  of  lympli 
in  excoHH  of  llial  rcfuiiicd  for  I  he  roparal  ivo  ])i-ocosrf 
is  an  excelleni  cull  me  medium  for  the  growth  of  any 
gerniH  vvhieli  may  have  neenred  lodgenvnt  iti  the 
wound  and  i-cMuaiued  ujiliarmed  by  I  he  ciiemical  in  tlie 
irrigating  fluid.  By  this  it  is  ])lain  that  this  trouldc 
can  be  avoided  by  careful  attention  to  aseijsis. 

Control  of  Hemorrhage,  and  Suturing  Wounds. — When 
practicable,  all  bleeding  should  be  controlled  l)y  for- 
ceps  pressure,   ligation   with  catgut,  torsion,   or  hot 
water,  and  the  wound  sponged  dry  before  attempting 
to  approximate  its  surfaces.     The  deeper  portions  of 
the  wound  may   be   approximated   by    buried,    inter- 
rupted,   or,   better    still,    continuous    catgut    stitches. 
The  skin  surface  can  be  sewed  so  as  to  accurately 
bring  the  edges  together,  either  by  using  interrupted 
stitches  or  the  continuous  stitch;    sometimes  a  com- 
bination of  both.     Silkworm  gut  and  silk  are  prefera- 
ble for  the  interrupted  stitches,  and  catgut  or  flue  iron- 
dyed  silk  for  the  continuous  line.     Whenever  flne  silk 
is  used  as  a  sewing  material,  the  iron-dyed  is  the  best, 
as  it  is  more  easily  seen,  and  therefore  can  be  more  ac 
curately  and  neatly  used  than  white  silk.    When  there 
is  little  tension  in  the  deeper  portions  of  a  dry  wound 
the  skin  may  be  sutured  and  the  deeper  parts   suf- 
ficiently brought  together  by  the  gentle  pressure  of 
suitably  arranged  dressings  and  bandages.    When  the 
deeper  parts  of  a  wound  cannot  be  brought  together 
from  the  bottom  up,  enough  blood  may  be  allowed  to 
escape  from  the  vessels  to  fill  this  space,  and  the  skin 
closed  by  accurate  suture.     By  proceeding  in  this  way 
we  take  advantage  of  the  well  known  method  of  repair 
called  ''healing  by  blood  clot."     In  this  the  clot  acts 
as  a  mold  into  which  the  leucocytes  and  connective 
tissue  corpuscles  and  derivatives  in  the  exudate  from 
the  wound  surface  penetrate  the  clot.     As  a  result  of 
their  combined  action,  connective  tissue  is  developed 
throughout  the  clot,  which  is  said  to  become  organized. 
In  this  process  the  clot  merely  assists  the  cells,  both 
as  a  framework  and  as  a  food  supply. 


IG  MODERN    TRKATMKNT    01'    WOUNDS. 

It  is  not  wise  to  shut  ulT  parts  of  a  deep  wuiiiid  lium 
Others  by  means  of  buried  sutures,  when  by  so  doing 
spaces  are  left  which  do  not  join  each  other  from  the 
lowest  to  the  surface,  because,  should  by  ehance  in- 
fection have  taken  place  before  the  closure  of  the 
wound,  strong  barriers  are  built  against  the  escape  of 
pent-up  poisonous  materials,  with  consequent  local, 
and  perhaps  constitutional,  disturbances.  A  drain 
made  of  sterile  gauze  or  rubber  tubing  should  be 
placed  so  as  to  facilitate  the  escape  of  any  super- 
abundance of  lymph  or  blood  likely  to  accumulate  in 
pockets.  This  drain  should  not  be  allowed  to  remain 
longer  than  twenty-four,  or,  at  the  longest,  forty-eight 
hours. 

It  is  often  wise  to  favor  rest  by  the  use  of  splints, 
even  where  no  bones  or  joints  are  involved.  Wounds 
of  the  face  and  neck  should  be  closed  with  the  most 
painstaking  care,  using  buried  catgut  stitches  for  deep 
wounds,  and  for  the  skin  the  subcuticular  stitch  of 
Marcy  ("blind  stitching"  of  our  grandmothers).  Very 
fine  silk,  tendon,  or  catgut  introduced  with  a  well- 
curved  needle  may  be  employed  for  the  skin.  It  is 
better  to  dispense  with  the  needle-holder  in  making 
this  stitch.  A  cotton  or  gauze  collodion  dressing  aids 
in  the  accuracy  of  the  approximation  of  the  skin  edges, 
and,  in  special  cases,  it  may  be  a  good  plan,  in  order 
to  secure  rest  after  closure  of  extensive  neck  wounds, 
to  steady  the  head  by  a  plaster  bandage  passed  over 
copious  padding  around  the  neck,  head,  and  shoulders. 

In  operation  wounds  in  which  it  is  necessary  to 
sacrifice  a  considerable  area  of  skin,  it  is  often  well  to 
dissect  up  the  flaps  from  the  underlying  tissue,  in 
order  to  allow  of  the  easier  approximation  of  the 
edges.  Before  sewing  the  edges  together  one  or  sev- 
eral tension  sutures  should  l)e  introduced  after  the 
fashion  of  the  quilted  suture. 

Tension  F^itturef<. — An  iodoform  gauze  pad  should 
be  placed  on  the  skin  under  the  loop,  and  also 
between  the  free  ends  of  the  suturing  material,  be- 
fore making  traction  and  tying.  This  widens  the 
areas  of  pressure  and  prevents  the  suture  from  cut- 


OPBKATIVE   AND   AO(!1D)0.\'1'A  I>    VVOI.MiS.  17 

ting.  When  i(;  is  imj>OHHibl<'  lo  dinw  tlio  <,'(J^'fs  of  u 
wound  together,  or  wlien  hy  doing  ho  the  niilrilion  of 
the  flaps  may  be  in  part  destroyed,  it  is  well  to  close 
the  gap  as  much  as  possible  without  employing  too 
great  tension  upon  the  flaps.  After  doing  this,  the 
raw  surface  may  be  covered  with  skin  grafts,  either 
immediately  or  after  the  formation  of  granulation 
tissue.  It  is  possible,  by  painstaking  asepsis,  to  bring 
about  repair  of  these  open  wounds  without  the  fonn;' 
tion  of  pus. 

Dressing  of  N  on- Suppurating  Wounds. — Aseptic 
wounds,  from  which  no  leakage  is  expected,  may  be 
sealed  v/ith  a  collodion  dressing  and  further  protected 
by  small  quantities  of  dry  sterile  gauze  and  cotton, 
secured  by  a  bandage.  Six  or  eight  thicknesses  of  dry 
sterile  gauze  in  the  form  of  a  pad,  somewhat  larger 
than  the  field  of  operation,  may  be  put  directly  over 
the  wound.  Absorbent  cotton  is  placed  over  this  and 
the  dressing  is  fastened  by  the  bandage.  The  cotton 
should  be  liberal  in  quantity  and  should  cover  any 
bony  prominences  which  may  be  encircled  by  the  ban- 
dage or  binder.  When  drainage  has  been  provided 
for,  the  gauze  dressings  should  be  heavier  and  some 
impermeable  material,  such  as  florists'  paper,  rubber 
tissue,  etc.,  which  has  been  placed  in  a  1-20  solution  of 
carbolic  acid,  or  a  1-.500  solution  of  corrosive  sublimate 
is  spread  out  between  the  gauze  and  cotton.  This  pre- 
vents infection  of  the  wound,  which  might  result  from 
a  putrefaction  of  the  discharge,  the  germs  gaining  en- 
trance from  without.  In  that  class  of  aseptic  wounds 
in  which  it  has  been  impracticable  to  suture  the  skin 
over  all  of  the  raw  surfaces,  the  dressing  should  be  the 
same  as  just  described,  with  the  addition  of  a  second 
piece  of  sterilized  rubber  tissue,  slightly  larger  than 
the  raw  surface,  which  is  placed  directly  upon  it.  The 
rubber  prevents  the  gauze  from  sticking  to  the  wound. 
Numerous  openings  are  cut  in  the  rubber  tissue  to 
allow  of  the  escape  of  the  secretions  into  the  gauze. 
This  same  form  of  dressing  is  essential  if  skin  grafts 
have  been  used. 

Behavior  of  Supposedly  Aseptic  Wounds. — After  the 


18  .\iiiiii:i;\    1  i:i:ai'.\ii:n  r  oi'   \V(»inds. 

closuir  and  clri-ssin^^  of  \hv  class  of  wouiuls  uiuler  roii- 
sideratioii.  ilu'if  may  W  a  (,'t»iiij>U'i('  abseiu'c  of  pain, 
or  only  a  little  smarting  complained  of,  the  tempera- 
ture leniainiug  at  normal,  or  slightly  above  normal. 
Shonld  the  temperatni'e  be  101"  Fahr.,  or  higher,  and 
pain  in  the  wound  eomi)lained  of  after  forty-eight 
hours,  especially  if  the  tongue  is  coated  aud  the 
patient  is  restless,  the  dressings  should  be  removed 
and  the  wound  inspected.  If  there  are  no  signs  of 
inlhimmation,  the  condition  is  probably  due  to  a  lock 
ing  up  of  the  seci'etions.  The  dressings  are  replaced 
and  a  brisk  cathai'tic  administered.  Should  the  tem- 
perature remain  elevated  after  the  bowels  have  moved, 
the  cause  is  probably  some  suppuration  in  the  deeper 
parts  of  the  wound,  and  an  avenue  of  escape  should  Im? 
made.  This  is  done  by  removing  one  or  more  stitches, 
preferably  at  the  most  dependent  part,  separating  the 
edges  at  this  place  and  exploring  the  deeper  parts  of 
the  wound  with  dressing  forceps.  Pus  will  commonly 
be  found,  and  the  tract  made  by  the  forceps  should  be 
widened  by  separating  the  blades  of  the  instrument  on 
withdrawing  it.  A  drain  should  be  introduced  well 
towards  the  source  of  suppuration.  Years  ago  it  was 
the  fashion  to  Siiueeze  and  irrigate  such  wounds,  but 
experience  has  taught  that  they  do  better  if  a  drain  is 
introduced  and  a  wet  antiseptic  dressing  applied.  By 
following  this  practice  there  is  less  disturbance  of  the 
healing  process  in  the  uninfected  parts  of  the  wound, 
and  the  discharge  is  freely  conducted  out  of  the  w^ound 
and  rendered  innocuous  by  mixing  with  the  antiseptic 
in  the  moist  dressing.  This  diessing  is  the  same  as 
that  for  an  asei)tic  wound  where  oozing  is  expected, 
and  a  single  piece  of  oiled  paper  or  rubber  tissue  i» 
used  and  placed  between  the  gauze  and  cotton,  only,  in 
addition,  the  gauze  is  soaked  in  a  fairly  sti-ong  antisep- 
tic solution,  as  1-1,000  bichloride,  and  ]»arlly  wrung  out 
before  being  ai>i)lied  against  the  wound  surface.  If 
the  inflammation  be  superficial,  whether  there  be  ten- 
sion or  not,  enough  stitches  should  be  cut  to  allow  of 
free  drainage  and  the  open  part  of  the  wound  gently 
sponged   with   cotton  soaked  in  a  1-20  carbolic  acid 


OI'KKA'I'IV  i;    AND    AOC;iI)I0.N"l'AI.   WOIIN'DH.  1!) 

solution.  Jodofonii  powder  dkiv  Ix*  diiHtf'd  onto  the 
wound,  bill,  ^ciHM-ally  Hpcakiiig,  all  powdcrH  tend  to 
i'(^(ai'd  lu'alinj;-  W.v  niixiiij^  willi  ( he  HccrctionH  and  foi-rn- 
ing  cnisU  under  wliicli  discliaiges  are  retaiued.  Tlie 
wet  bichloride  dressing  is  best  in  the  early  stag&s  f)f 
these  ]»ai<ially  su])])in'af in^  wounds. 

If  the  general  coiidilion  of  llie  |>ali<iit  is  al)oiil 
normal  these  wounds  need  not  b(;  redressed  oftener 
than  every  forty-eight  hours.  When  the  dressings 
are  changed,  the  wound  should  be  sponged  clean  willi 
cotton  or  gauze,  wet  in  an  antise])tic  solution  (bichlo- 
ride, 1-1, ()()())  and  cai-efully  inspecled.  If  inllaniinalion 
has  not  spread  to  other  parts  and  the  wound  looks 
healthy,  nothing  further  is  necessary  than  to  reax>ply 
the  dressings. 

Treatmcfit  of  Infection  of  Supposedly  Aseptic  Wounds. 
— Should,  however,  other  parts  of  the  wound,  either 
at  the  edges  or  stitch-holes,  show  a  further  infec- 
tion, even  if  only  slight,  the  stitches  must  be 
taken  out.  If  pus  does  not  show  itself  at  the  stitch- 
hole  openings  upon  pressure,  the  lips  of  the  wound 
should  be  gently  separated  and  a  smaller  or  greater 
amount  of  pus  will  be  found.  A  deep  wound  af- 
fected superficially  in  this  way,  without  much  swell 
ing,  deeply  situated  pain,  or  elevation  of  temperature, 
should  not  be  further  disturbed  by  opening  it  up.  An 
attempt  may  be  made  to  thoroughly  destroy  all  germs 
present,  both  on  the  infected  surfaces  and  in  the  tis- 
sues themselves,  by  using  some  strong  antiseptic, 
which  also  has  cauterizing  properties.  In  liquid  car- 
bolic acid  we  have  such  an  antiseptic,  and  the  pain  and 
cauterizing  action  of  the  acid  can  be  immediately  con- 
trolled by  applying  alcohol  directly  to  the  surface  upon 
which  the  carbolic  acid  is  acting.  For  open  surfaces, 
the  acid  and  alcohol  is  applied  on  cotton  held  in  a 
dressing  forceps.  For  stitch-holes  and  small  cavities 
and  tracts,  the  acid  and  alcohol  can  be  easily  made  to 
reach  every  point  if  applied  upon  cotton  wrapped 
around  a  probe.  After  such  treatment,  a  moist  anti- 
septic dressing  should  be  used  and  changed  daily.  It 
may  be  necessar^^  to  employ  the  carbolic  acid  and  alco 


'20  MODERN   TREATMENT    OK    W»)l  NDS. 

hol  a  second  time.  Iodoform  gauze  may  be  used  \\\[h 
advantage  as  a  material  to  be  gently  packed  into  the 
wound.  The  iodoform  aets  by  modifying  the  action  of 
pus-producing  germs,  although  it  does  not  prevent 
these  germs  from  multiplying;  the  gauze  acts  as  a 
drain.  Should  the  whole,  or  a  greater  part,  of  the 
wound  become  infected,  it  should  be  opened  up  from 
top  to  bottom  and  managed  as  indicated  abt>ve. 

Should  thei'^  be  a  tendency  to  sloughing,  with 
maceration  and  putrefaction  of  sloughs,  there  is  no 
agent  which  will  check  this  so  (juickly  as  formalde- 
hyde (40  per  cent,  solution).  Of  this  we  use  for  s])Oiig 
ing  and  irrigation,  a  solution  in  water,  of  a  strength 
varying  from  one  dram  to  one  ounce  to  the  quart.  If 
wounds  remain  aseptic  and  drainage  has  not  been  em- 
ployed, dressings  need  not  be  disturbed  for  from  five 
to  ten  days,  according  to  the  character  and  position  of 
the  wound. 

Stitches  and  Their  Extraction. — Usually  stitches 
have  served  their  purpose  at  the  end  of  these  periods, 
and  should  be  removed.  To  remove  an  interrupted 
stitch  it  should  be  cut  close  to  its  entrance  into  the 
skin  on  one  side  and  then,  with  a  forceps,  it  is  ex- 
tracted by  gently  drawing  the  long  end  toward  the 
side  which  was  cut.  By  taking  out  threads  in  this 
way  there  is  little  danger  of  separating  the  lips  of 
the  wound,  should  union  be  weak.  The  extraction 
of  interrupted  stitches  is  made  easier  if  the  knots 
are  all  tied  upon  one  side.  This  tying  is  done  by 
drawing  one  end  of  the  stitch,  after  tightening  the 
first  loop,  towards  and  across  the  wound,  thus  bring- 
ing the  knot  almost  directly  over  the  point  of  en- 
trance of  the  other  end  of  the  stitch  into  the  skin. 
In  wounds  of  the  scalp,  and  often  in  other  localities, 
it  is  especially  desirable  that  tension  upon  the 
stitches  should  never  be  allowed,  that  is,  post-opera- 
tive tension  due  to  inflammation  or  the  accumula- 
tion of  fluids  under  the  flaps.  To  prevent  this,  and  still 
at  the  same  time  give  accurate  and  sufficient  sup])ort 
for  normal  conditions,  interrupted  stitches  of  well- 
softened  silkworm  gut  sliniild  be  iis<'d.     One  end  of  the 


(»i'i<;):a'I'i\'K  and  aocidiontai.  wor-NDS.  "il 

sdtcli  is  carried  Lwicc  around  Llie  oNk-i-  and  lighu-jiod 
directly  acrosH  the  lips  of  the  Avoiuid.  This  is  the 
''surgeon's  knot,"  without  the  final  or  fasten! jig  loop. 
These  slilehes  give  sufficient  supjiort  for  normal  i-e- 
]»air,  but  will  give  away  under  abnormal  tension.  In 
removing  a  continuous  stitch  it  should  be  cut  along 
one  side  close  to  every  skin  puncture,  and  the  sepa- 
rated parts  removed  as  are  interrupted  stitches.  The 
subcuticular  continuous  stit(;h,  used  for  api)roxirna- 
tiou  of  skin  edges,  is  removed  by  making  traction  upon 
one  end.  Stitches  of  absorbable  material  should  not 
be  interfered  with,  unless  they  j)roduce  irritation, 
when  no  time  should  be  lost  in  taking  out  every  parti- 
cle, for  they  serve  too  well  as  culture  media  for  germ 
growth.  Aftei'  the  removal  of  stitches  it  is  often  well 
to  give  support  to  the  newly  repaired  wound  by  using 
collodion,  or  where  a  strain  may  be  expected,  adhesive 
plaster  is  useful.  Especially  made  binders  are  almost 
essential  for  the  support  of  long  wounds  through  the 
abdominal  walls.  Many  surgeons  insist  upon  their 
patients  wearing  these  supporters  in  order  to  prevent 
the  formation  of  hernia,  which  is  apt  to  occur  in  a  small 
percentage  of  case^  after  abdominal  section.  In  fat 
subjects  and  those  having  much  lifting  to  do,  the  sup- 
port should  be  worn  six  months,  or  even  longer. 


Min>i:i;\    iiji:a  I'.MKN  r  or  wounds. 


(MIArTEii  1\  . 
'.h'i:k.\ii().ns  on  infected  tissues. 

W  imiiils  Madt  into  Infcclcil  V'/.vm/c.v. — NN'hcii  il  is  ucc- 
I'.ssarv  i<i  lujikf  iiicision.s  ihrou^^h  ;ii»j)ar('nily  Iicallliv 
tissiU's  in  (H-dcr  lo  reach  infected  areas,  i(  is  usually 
best  to  treat  the  lesiiltiug  wound  as  one  wliicli  must 
ro])aii'.  in  pai-t  at  least,  by  granulation  with  tlie  foiina- 
lion  of  pus.  Should  the  operator  feel  sure  that  all 
foci  of  supj)Uiation  have  been  i-euioved.  even  if  tlie 
wound  lias  been  moi'e  or  less  soiled  by  i)us  during  the 
excision,  after  thorough  disinfection  it  may  follow 
that  by  accurate  suture  complete  re]»air  will  take 
place,  union  being  by  first  intention.  However,  such 
a  result  is  rather  exceptional.  Usually  there  will 
be  a  gresiter  or  less  failure  of  the  primary  reparative 
process,  and  some  su])puration  t<)llow.  Therefore  it 
is  wiser  to  close  such  wounds  in  part  only,  leaving  at 
the  most  dependent  place  an  (>i)ening  extending  from 
the  bottom  to  the  surface.  A  drain,  either  of  rubber 
tubing  or  iodoform  gauze,  should  be  inserted,  and  if 
after  forty-eight  hours  thei'e  is  comi)lete  i'vidence  of 
the  absence  of  inflammation  in  the  wound,  the  di'ain 
ought  to  be  removed.  This  diain  acts  as  a  safety 
valve,  should  the  effort  to  obtain  primary  repair  prove 
futile.  In  eithei-  case,  the  di-essings  and  ti-eatment 
should  be  as  indicated  for  non-infected  wounds,  or 
those  made  by  the  surgeon  in  which  a  faulty  techuniuc 
was  rewarded  by  more  or  less  infection. 

If  an  incision  is  carried  directly  through  inflamed 
tissues,  although  there  is  an  absence  of  surface  sup- 
puration, the  prime  object  of  the  use  of  the  knife 
\\(>ul(l  lie  lost  unless  the  wound  were  kept  open. 
These  incisions,  whether  single  or  multii»le,  long  or 
short,  are  made  for  the  purpose  of  relieving  tension, 
and  for  the  evacuation  of  fluids  whose  retention  may, 
in  a  circumscribed  or  spi-eading  fashion,  tend  to  cause 
pail),  jirolong  illness,  or  even  threaten  limb  or  life. 
Tli<M-i"fore,  fre<'  di  aiuagc  must  always  1»e  eni]>loyed  and 


OI'IOKATIONS    ON    I  N  I'MO*  I'l'IOI )   'IMSHIIKH.  23 

llie  j^i'cateHl;  car<'  iw  (jsHciiliaJ,  (lial.  while  u  iM.'parative 
proccNSH  is  Kiipi)laulin<^-  tlic  iiillaiuinatory  orio  in  the 
infeclcd  tisHucs,  no  liiiidrancc  slioiild  ]>('  allowed  1o  the 
free  escape  of  all  scercHioiis  from  llic  de<'])('st  iTT'eHsc'S 
to  the  skin  edge. 

In  acute  cii'cuinsci'ilted  inflamniatioiiH,  with  the  more 
or  less  com]»lc(:e  breakiiij^'  down  of  all  of  the  lissnes 
involv^ed,  it  is  usually  sulTi(Men(,  after  an  incision,  to 
gently  irrigate  the  Avound  cavity  with  an  antiseptic 
solution  of  medium  strength  (bichloride,  1-2,000)  and 
drain  by  using  a  light  iodoform  gauze  ])acldng,  the 
discharges  being  received  into  a  moist  antiseptic 
dressing  protected  by  some  impervious  covering.  The 
dressing  should  be  changed  daily  until  all  signs  of 
inflammation  have  disappeared;  usually  in  from  two  to 
five  days.  Then  it  is  better  to  use  as  a  drainage  ma- 
terial a.  strip  of  iodoform  gauze  soaked  in  castor  oil, 
or  in  castor  oil  and  balsam  Peru,  5  to  6  per  cent,  of 
the  latter.  Sterile  p-nnze  is  usually  quite  as  efficient 
as  the  iodoform  gauzc,  and  much  cheaper,  but  gener- 
ally it  may  be  stated  that  until  granulations  begin  to 
form  for  repair,  iodoform  gauze  is  better.  A  good 
sized  piece  of  sterile  gauze  soaked  in  the  oil  dressing 
is  placed  over  the  end  of  the  gauze  drain,  and  over  this 
is  arranged  some  oiled  paper  or  rubber  tissue,  and 
over  all,  cotton  and  a  bandage.  This  dressing  need 
not  be  changed  oftener  than  every  second  or  third  day. 
Irrigation  is  unnecessary,  as  there  is  nothing  to  wash 
away.  All  of  the  discharge  finds  its  escape  along  the 
drain  into  the  medicated  dressing  under  the  impervi- 
ous protective.  There  is  no  drying  out  and  sticking 
of  the  dressings  so  that  discharges  are  pent  up  and  de- 
composed in  the  wound.  Gradually,  as  the  wound  fills 
from  the  bottom,  the  dressing  should  become  smaller 
in  bulk,  and  as  the  granulations  reach  the  surface  of 
the  incision,  it  should  be  allowed  to  close.  This  may 
be  aided  often  by  drawing  the  edges  towards  one 
another,  using  adhesive  plaster.  Before  applying  the 
plaster  the  wound  must  be  protected  with  some  light 
non-irritating  antiseptic  dressing.  Boracic  acid  oint- 
ment of  about  one-fourth  strength  spread  on  lint  or 

3 


-i  Mi"»r>EnN    rriKAiMioN'r  of  \vi»i  nds. 

sicrilr  ^aii/.»-  is  ail  txii'lli'iii  drt-ssiii}^-  at  I  his  stage  of 
the  wound  icpaii-. 

In  infvctiotis  iit/ldiniitdtions  'nnolvimj  consiilt'rable 
areas,  as,  for  instance,  in  more  or  less  diffuse  cellulitis 
of  the  exti-einities,  or  of  the  parts  involved  in  extrava- 
sation of  urine,  the  only  hope  of  limiting  the  spread 
of  the  inlhinunatorv  process  is  to  establish  free  drain- 
age by  suitable  incisions.  Such  wounds  have  to  be 
kept  open,  using  large  fenestrated  rubber  drainage 
lubes  or  gauze.  The  rubber  tubing  is  ]>ref('iable,  and 
often  it  is  good  jiractice  to  connect  well  placed  open- 
ings by  the  same  piece  of  tubing.  Gentle  pressure  and 
irrigation  with  some  antiseptic  sohition  is  useful  to 
remove  pus  and  debris.  Little  good  is  to  be  expected 
from  the  irrigating  fluid  except  its  mechanical  action. 
So,  usually,  it  is  best  to  limit  this  interference  with 
repair  to  the  purposes  mentioned.  Copious  moist  an- 
tiseptic dressings  are  essential  and  these  must  be  re- 
moved every  twelve  to  twenty-four  hours  until  it  is 
evident  that  inflammation  has  ceased  to  spread  and 
that  repair  is  well  established.  In  addition  to  the 
tubing,  gauze  may  also  b(^  employed  to  aid  in  keeping 
the  incisions  from  closing  too  soon,  ^^■hen,  as  a  result 
of  the  incisions,  dressings,  etc.,  the  intlainmation  has 
become  a  local  one,  the  conduct  of  the  after  treatment 
should  be  along  the  same  lines  as  advised  in  acute 
circumscribed  inflammations.  It  may  be  evident, 
from  the  virulence  of  the  inflammation,  that  more 
severe  measures  of  treatment  are  necessary,  either 
after  the  line  of  practice  for  the  management  of  sup- 
jturative  cellular  inflammation  has  failed  to  stay  its 
spread,  or  where  from  the  first  simple  incisions  for  the 
purpose  of  drainage  were  recognizedly  insufhcient. 

Open  Drainof/e  for  Disinfeelion. — T'nder  such  circum- 
stances, it  is  often  the  best  practice  to  lay  the  parts 
wide  open  by  fiee  incisions,  not  only  with  the  purpose 
of  gaining  absolutely  oi)en  drainage,  but  also  an  ap- 
portunity  to  mop  the  infected  tissues  with  liquid  car- 
bolic acid  or  tincture  of  iodine  (])0ssibly  somewhat 
diluted  with  al<-ohol).  These  strong  antiseptic  agents 
will  usually  i)enetrat«'  so  as  to  destroy  the  infecting 


onOHATIoNH    OX    IM''IO<"I'IOIJ   'I'ISSIIKH.  25 

(ik^iiu'iil  and  as  a  icsiili  cHlahliHli  Ji  r<.'piii'al,ive  in  tli<; 
place  ol'  an  inreclivc  proccHH. 

DrcsHlng  After  Disinfection. — Iodoform  gauze  is  t  Ik- 
best  material  to  lightly  pack  into  Uuw.  wounds,  an<l 
the  packing  and  anti.sejdic  droHHingH  Hhould  be 
changed  once  oi-  twice  every  I  wenly-foni-  luinrs  until 
the  discharge  becomes  moderate  in  amount  and 
healthy  in  character.  (Jampho-i)henique  gau/.e  is  a 
valuable  drainage  material.  It  is  antiseptic,  anes- 
thetic, and  drains  a  little  better  than  iodoform 
gauze.  Occasionally  incisions  for  the  relief  of  the 
tension  and  spread  of  cellular  inflammation  are  made 
so  late  that  intermuscular  planes  have  become  in- 
vaded and  pus  has  found  its  way  towards  i^arts  at 
some  distance  from  the  surface.  Such  circumstances 
will  be  discovered  by  the  exploring  finger,  always  in- 
troduced into  the  incisions  for  the  purpose  of  ascer- 
taining whether  or  not  this  condition  is  present. 
When  so,  the  drains  must  be  placed  so  as  to  reach 
the  bottom  of  the  infection,  and  perhaps,  in  order  to 
do  this  and  perfect  the  drainage,  it  may  become  nec- 
essary to  make  dependent  openings  through  healthy 
tissues.  This  is  most  commonly  necessary  in  the  ex- 
tremities when  so-called  ''through  and  through  drain- 
age" is  established.  In  freely  opened  septic  wounds, 
irrigation  at  each  dressing  is  required  to  loosen  and 
help  wash  away  sloughs  formed  as  a  result  of  the  in- 
flammation and  powerful  antiseptics  employed. 

As  the  repair  progresses,  drainage  tubes  should  be 
shortened.  Often  tubes  of  small  caliber  can  be  sub- 
stituted for  the  larger  ones.  These  extensive  sup- 
purating processes  are  very  depressing  and  the  sys- 
tem should  be  supported  by  alcohol,  strychnine,  and 
forced  feeding.  Opium  should  be  given  to  control 
pain,  and  in  the  later  periods  of  the  infection  to  check 
diarrhea. 


I'd  mc»di:k.\  tkeat.mknt  ui'  wolnds. 

GHAPTEK  V. 

ACCIDENTAL  WOUNDS. 

Wimnds  Xot  InfUrtcd  hy  ihv  Siiri/con. — When  ;u-ci- 
deiital  woiiuds  are  of  Iho  uatiire  of  incised  wounds 
tliej  are  treated  much  the  same  as  are  wounds  made 
by  the  surj^eon  Ihronjih  non-infected  tissues.  The 
surfaci'  about  the  wound  is  i>repared  by  the  method 
given  for  an  antiseptic  operation.  In  addition,  the 
lips  of  the  wound  should  be  se])arated  and  the  raw 
surface  disinfected.  Great  care  must  be  taken  to  re- 
move any  foreiiiu  nuitcrial,  and  esi»ecially  sliould 
this  be  insisted  upon  if  the  circumstances  of  the  in- 
jury i)oint  towards  the  jtossibility  of  street  or  stable 
dirt  having  gained  entrance  into  the  wound,  because 
of  the  dan.uer  of  the  presence  of  th.^  telanus  bacillus 
in  such  din.  Under  these  conditions,  th:-  disinfection 
should  be  most  thorough.  Alcohol,  liquid  carbolic 
acid,  and  tincture  of  iodine  are  among  the  most  useful 
agents  for  this  disinfection.  If  the  surgeon  is  reason- 
ably certain  that  he  has  a  clean  wound  to  deal  with, 
it  ought  to  be  sutured  and  some  suitable  antiseptic 
dressing  applied.  Under  all  other  circumstances  it 
is  wiser  to  leave  the  wound,  in  part  at  least,  unsu- 
tured.  An  antiseptic  dressing  must  be  used.  If  af- 
ter a  few  daj^s  there  is  complete  absence  of  inflamma- 
tion, the  wound  may  be  closed  by  suture  or  the  edges 
approximated  with  adhesive  plaster  drawn  over  anti- 
se])tic  gauze  apidied  next  to  the  wound.  If  infection 
has  taken  place,  the  treatment  should  be  as  already 
described  for  similar  conditions. 

The  nature  of  an  accidental  (possibly  homicidal  or 
suicidal)  incised  wound  may,  from  its  anatomical  lo- 
cation, prevent  any  ])riniary  attemj)t  at  cleanliness, 
because  of  threatened  danger  to  life  from  hemor- 
rhage, but  after  this  has  been  overcome,  thorough  an- 
tiseptic details  should  be  followed.  If  nerve  tninks  or 
muscles  have  been  divided  the  ends  should  be  care- 
fully sewed  to  their  proper  fellows  before  closing  the 
wrund.     These  kinds  of  complicated  incised  wounds 


AC(1(I)10N'I'A1>    WOUNDS.  27 

ai/e  most  olteii  seen  near  joints  whci"<;  muscles,  Loi- 
dons,  and  nerves  are  situated  in  shallow  spaces  be- 
tween the  skin  and  (lie  bones.  Incised  wounds  of 
si)ecial  parts  of  I  he  body  must  be  dealt  with  according 
to  the  recognized  surgery  of  the  particular  structures 
or  organs  involved.  Categorically  speaking,  it  may  be 
stated  that  the  control  of  hemorrhage  should  be  the 
first  object.  The  second  should  be  llic  removal  of  all 
foreign  substances,  as  dirt  from  without,  or,  in  case  of 
a  wound  of  the  intestine,  soiling  from  within.  Third, 
after  thorough  cleansing,  all  damage  should  be  most 
painstakingly  repaired.  These  must  be  dealt  with 
before  any  attempt  at  closure  of  the  outside  wound 
is  undertaken. 

Simple  contusions,  or  hruises,  are  best  treated  by 
hot  water,  used  by  immersion  if  the  injury  is  of  an 
extremity.  When  the  head  or  trunk  is  the  locality 
injured,  cloths  wrung  out  of  hot  water  and  frequently 
changed  are  very  effective.  Tliis  treatment  lessens 
swelling,  checks  extravasation  of  blood,  and  relieves 
pain.  After  the  first  twenty-four  hours,  gentle  mas- 
sage may  be  begun  and  continued  daily.  A  flannel 
bandage  applied  directly  to  the  skin,  or  over  cotton  or 
lamb's  wool,  is  effective  in  giving  support  and  in  aid- 
ing absorption  of  extravasated  blood  and  irritation 
exudate. 

Lacerated  ivounds,  which  may  be  more  or  less  con- 
tused or  crushed,  are  of  the  most  serious  class  of 
injuries  the  surgeon  is  called  upon  to  treat.  The  ex- 
tent of  destruction  of  both  soft  parts  and  bones  is  not 
uncommonly  so  great  that  the  shock  to  the  nervous 
system  is  overw^helming  and  causes  death  either 
immediately  or  within  a  few  hours.  Fortunately  mild 
tearing  and  bruising  of  the  tissues  is  the  rule;  the 
more  serious  injuries  result  from  entanglement  in 
heavy  machinery,  or  the  mutilation  of  limbs  by  car 
wheels. 

Shock. — Lacerated  wounds,  whatever  their  kind, 
require  an  especial  examination.  Before,  however, 
expending  any  time  further  than  to  perhaps  remove 
the  clothing  so  as  to  gather  a  respectable  idea  of  The 


2S  M(ti>i:u\    ruKAiMKNi"  ok  wor.Nns. 

charactiT  ol  ilu-  injury,  the  general  couditimi  of  ilic 
patient  should  be  investigated.  If  there  is  iniiiked 
deran^aMuent  of  the  nervous  system,  e\idenced  by  a 
small,  unnaturally  rapid  i>ulse,  paiiial  miconseicuis 
ness.  or  an  exhilarated  state  of,  "riu  all  right," 
clammy  skin  and  pale  or  ashen  face,  restorative  meas- 
ures are  necessary  before  any  attention  to  the  injury 
itself  is  undertaken,  unless  luMuorrliage  is  going  on. 
When  there  is  any  hemorrhage,  even  though  moderate 
in  amount  it  should  be  checked,  catching  the  bleeding 
vessel  or  vessels  with  artery  clamps  will  suffice  for 
moderate  sui)erhcial  bleeding,  but  when  the  blood 
comes  from  several  vessels  of  large  size  and  man}- 
small  vessels,  as  may  be  the  case  in  some  injuries  of 
the  extremities,  the  best  practice  is  to  apply  an  elas- 
tic tourniquet  so  as  to  control  the  bleeding.  If  the 
patient's  general  condition  is  so  bad  that  a  furthei' 
examination  might  add  to  the  shock,  it  is  wrong  to 
interfere.  The  shorter  the  distance  a  patient  suffer- 
ing with  severe  shock  is  moved  from  the  place  of  ac- 
cident to  where  he  may  receive  first  aid,  the  better. 
The  essential  restoratives  are, — after  checking  bleed- 
ing and  applying  some  protective  antiseptic  dressing, 
— absolute  quiet,  artificial  heat,  the  administration  of 
drugs.  Des])erate  cases  require  nice  judgment,  and 
in  the  administration  of  drugs  to  combat  shock,  the 
desire  to  do  something  often  warps  one's  judgment. 

For  many  years  alcohol  and  ojiium  were  the  sheet 
anchors  in  the  treatment  of  shock,  but  of  late  abohol 
is  being  discredited  and  not  much  is  heard  of  o])ium. 
The  hypodermic  administration  of  strychnia  is  the 
remedy  most  relied  upon,  and  in  case  of  much  loss  of 
blood,  its  volume  is  replaced,  in  i)ait  at  least,  by  the 
intravenous  injection  of  hot  normal  salt  solution. 
The  strychnia  is  given  in  doses  of  1-8(1  gr.  to  1-10  gr., 
repeated  every  one  to  four  hours,  Tr.  digitalis,  10  m., 
30  m.  may  be  given  hypodermically.  Nitroglycerine. 
1-100  gr..  and  atr()]tia.  1-100  gr.  are  often  used.  It  is 
the  opinion  of  the  writer  that  opium  in  the  form  of 
morphine  is  useful,  in  fact,  a  sine  qua  non  in  bringing 
about  an  equilibrium  in  the  nervous  system,  it  is  also 


A(;<;n»io.\'i'Ai.  wocxds.  29 

51  i)OW('il'ul  wliiMulunl.  LivcH  are  occiisionall y  Hacii- 
iiced  by  the  administration  (>f  too  many  and  too  pow- 
erful ''heart  f^limulants."  Absolute  quiet  brouf^ht 
about  by  favoiable  surroundingH  and  I  lie  use  of  juHt 
enough  nioi'phine  to  Hoolhe  the  disordered  nervous 
system  are  of  more  value  than  all  <d'  the  so-calhid 
heart  stimulants.  Strychnia  acts  as  a  stimulant  to 
the  respiratory  and  circulatory  centers;  it  also  has  a 
direct  stimulating  effect  upon  the  heart  muscle,  but 
strychnine  acts  upon  the  vasomotor  nerves  and  con- 
tracts the  arteries.  It  is  often  observed  that  the  pulse 
of  shock  indicates  the  presence  of  an  abnormally 
small  amount  of  blood  in  the  arteries;  the  superficial 
veins  indicate  the  presence  of  a  full  quantity  of  bloo<i 
in  these  veins,  and  it  is  reasonably  sure  that  the  ab- 
dominal veins  are  pretty  full.  Although  strychnia  does 
stimulate  the  heart,  unless  given  in  a  well  guarded 
manner,  it  ma^^  so  contract  the  arteries  as  to  increase 
the  accumulation  of  blood  in  the  veins  and  overwhelm 
the  right  heart.  Therefore,  when  strychnia  is  given 
in  large  doses  it  should  be  administered  in  conjunc- 
tion with  nitroglycerine  or  belladonna,  preferably  the 
latter  if  the  skin  is  cool  and  clammy.  Digitalis  pos- 
sesses, in  a  measure,  the  properties  of  strychnia;  its 
action  upon  the  blood  vessels  is  less  marked,  however, 
and  may  often,  with  advantage,  be  substituted  for  it. 
Digitalis  helps  to  unload  excrementitious  materials 
by  its  action  upon  the  kidneys  and  thus  adds  to  its 
usefulness. 

Contused  and  lacerated  woioids,  whatever  their  de- 
gree, require  careful  antiseptic  digital  examination 
to  determine  the  extent  of  injury  to  the  soft  parts,  and 
often,  also,  to  the  bones.  Most  any  kind  of  grease, 
dirt  or  foreign  substance,  may  have  been  forced  into 
the  deeper  recesses  of  the  wound,  so  the  future  be- 
havior of  the  wound  will  depend  upon  our  ability  to 
remove  all  such  material  and  thoroughly  disinfect. 
In  such  wounds,  except  those  of  a  trivial  kind,  drain- 
age must  be  established.  Whenever  there  is  exten- 
sive laceration  and  disturbance  of  the  soft  parts,  es- 
pecially if  bones  are  broken,  several  openings  ought 
to  be  arranged  and  rubber  tubing  placed  to  provide 


30  MttUKKN     rUKATMKNr    OF    WolNHS. 

ioi-  ;i  free  escape  of  hem<>rrhaji;if  and  t'Xiulative  tliiids. 
If  I  lie  suii;tH)ii's  I'lVorts  to  remove  all  infection  pro- 
duciii^-  8iil)slanees  have*  bci-n  uusuceessrul,  the  drain- 
Aiif  iuIk's  alVord  an  fst-apc  of  inllannnatorv  ]>rodiiets 
autl  I  he  dan{4;er  of  eonstihitional  i)Oisonin<^f  and  local 
intlannnatorv  destruction  are  reduced.  Copious  irri- 
gations with  some  strong  antiseptic  Huid,  as  bichlo- 
ride l-r)(i(),  l-KMM).  or  carbolic  acid,  1-20.  is  demanded 
in  the  first  ])reparation  of  the  wound.  Later,  milder 
irrigating  solutions  can  be  used.  Antiseptic  dress- 
ings sliould  envelope  these  wounds,  and  even  when 
bones  are  uninjured,  it  is  often  wise  to  employ 
splints  when  the  wounds  are  of  the  extremities, 
especially  if  in  close  proximity  to  joints.  The  quieter 
the  parts  are  kept  the  (juicker  the  repair  and  more 
circumscribed  any  inllammatory  condition  that  may 
arise. 

Lidivations  for  Ainpuiution. — iSometimes  it  is  good 
practice  to  cut  away  certain  soft  parts,  whose  vitality 
is  destroyed'  but  unless  this  tissue  is  merely  hanging 
by  shreds,  it  is  wisdom  to  wait  until  nature  has  dem- 
onstrated positively  the  death  of  tissue.  When,  from 
the  nature  of  the  crushing  force,  combined  with  a  care- 
ful examination  of  a  resulting  wounding  of  an  ex- 
tremity, it  is  positively  certain  that  the  blood  supj)ly  is 
totally  destroyed,  amputation  is  demanded,  and  this 
operation  ought  to  be  done  as  soon  as  reaction  from 
shock  is  established.  This  refers  to  profound  shock, 
which  nearly  always  exists  when  more  than  one  ex- 
tremity is  crushed  or  the  injury  is  near  the  trunk,  es- 
pecially of  the  lower  extremity.  When  shock  is  not 
very  marked  and  an  extremity,  or  extremities,  hope- 
lessly devitalized,  the  sooner  amputation  is  done  the 
better,  as  the  removal  of  such  parts  lessens  nerve  irri- 
tation. Moreover,  the  danger  of  septic  infection  is 
reduced.  If  the  blood  supply  left  after  one  of  these 
injuries  is  sufficient  to  keep  up  the  vitality  of  an  ex- 
tremity, it  should  never  be  amputated  as  a  primary 
procedure.  With  our  improved  modern  antise])tic  sur- 
gery, the  possibilities  of  repair  are  almost  unlimited. 
In  case  of  failure  to  preserve  a  useful  limb,  this  may 
be  removed  as  an  operation  of  election. 


ACOiinoNTAi.  woi;m>s.  :',l 

Fourlli  of  July  Acvidails. — There  is  n,  roriii  oT  \n<mi-- 
ated  wound  Hometiines  appeariug  of  little  coiiHeqiience, 
but  often  followed  by  lelanuH.  It  \h  generally  a  Fourth 
of  fiuly'  accident  and  follows  (lu^  (;nti';inc(;  of  small 
pieces  of  the  cap  used  on  ''toy"  pis(;ols,  parls  of  Dr.; 
crackers,  etc.  Wounds  caused  in  this  way  should  he 
freely  incised  so  as  (o  fjjet  al  the  dcH^pest  recesses  and 
remove  every  parti(de  of  foreign  substance'  discovera- 
ble. They  should  then  be  disinfected  with  pure  car- 
bolic acid  and  alcohol  and  kept  open  with  iodoform 
gau/e  packing-.  The  only  safe  way  to  treat  these 
wounds  is  upon  the  open  method,  I'epair  being  l>y  gran- 
ulation. It  ought  to  be  borne  in  mind  that  any  injui-y 
which  leaves  a  foreign  body  other  than  a  bullet  in  the 
tissues  is  liable  to  be  followed  by  tetanus. 

Punctured  wounds,  whether  from  their  anatomical 
location,  they  involve  joints,  organs  of  the  chest  and 
abdomen,  the  brain,  or  merely  soft  parts,  are  serious 
injuries.  When  the  inflicting  instrument  happens  to 
be  a  clean  one  the  wound  is  less  likely  to  be  danger- 
ous than  any  other  kind  of  wound,  provided  no  vital 
organ  is  injured,  t^ometimes  these  wounds  cause 
concealed  injury,  such  as  opening  into  an  intestine,  or 
bladder,  and  the  secondary  inflammation  may  be  fatal. 
The  chief  danger  of  punctured  wounds  lies  in  the  fact 
that  infective  germs  are  introduced  with  the  entering 
instrument,  and  the  nature  of  the  wound  tends  to  re- 
tain these  germs,  so  that  they  can  gain  a  firm  foot- 
hold. Wounds  which  bleed  freely  and  allow  of  an 
open  escape  of  blood  are  not  usually  infected  at  the 
time  of  their  causation.  Flowing  blood  does  not  favor 
germ  implantation  and  growth.  Punctured  wounds, 
unless  a  large  vessel  is  injured  in  the  direct  course  of 
the  puncturing  instrument,  seldom  bleed  much.  What 
bleeding  does  take  place  usually  extravasates  around 
the  track  of  the  wound;  therefore  any  germs  which 
enter  at  the  time  of  injury  are  securely  placed  for 
grovvth. 

Punctured  Wounds  of  Hands  and  Feet. — Punctured 
wounds  are  met  with  most  commonly  in  the  feet 
and  hands  and  are  often  followed  by  serious  con- 
sequences.    A  deep-seated   suppuration   mav  be   set 


',\2  MODKRN  TRKATMKNT  OK  WOrNOS. 

Up,  lomuu'iieiiig  in  the  aponeuroses,  decpor  connective 
tissue  or  tendon  sheaths,  and  because  of  the  resisting 
structure  of  the  anatomu  al  ariangeiin'nt,  supi)uial ion 
cannol  approach  tlie  siiita(c  iiniil  extensive  iinolve- 
ment.  even  (h'stiau-tion.  ol  iioi  unly  the  soft  jiarts.  hut 
also  the  bones  has  taken  phice.  Th 'i-e  is  invariably 
great  jiain,  greater  oi-  less  swelling  with  dnskv  red- 
ness. The  lingers  or  loes  soon  lose  ihcir  motility, 
likewise  tlte  wrist,  or  even  the  ankle.  If  active  sur- 
gical interference  is  not  insiituled  earl  v.  contraction 
of  the  teudons  and  palmar  oi-  plaiiiar  aponeurosis 
follows  with  permanent  disa])ility.  In  neglected 
cases,  sujipuration  ma.v  extend  upward  c<)usiderable 
distances.  High  fever  is  the  rule,  and  even  such  a 
grade  of  general  infection  nmy  occur  as  to  cause 
death. 

The  pi-oi)er  treatment  of  this  form  of  inflammation 
is  by  early,  fi-ee  incision;  tht*  knife  must  be  carried  to 
the  bottom  of  the  infection  and  gauze  or  tultular 
drainage  instituted.  'Sometimes  several  incisions  are 
necessary.  In  using  the  knife,  care  should  be  taken 
not  to  divide  tendons  or  the  arterial  arch(^s.  These 
latter,  however,  are  of  minor  importance.  After  di- 
viding the  more  superficial  parts,  the  finger,  or  some 
blunt  instrument,  may  be  used  to  reach  and  open  up 
the  deei»er  parts.  Incisions  shouhl  be  directed  in 
the  long  axes  of  the  tendons,  never  at  an  angle. 

These  inflammations  not  infi-equently  result  from 
slight  superficial  abrasions  sufficient  to  allow  of  tlie 
entrance  of  germs.  Again,  they  may  follow  bruises 
without  visible  breaking  of  the  skin.  This  is  ex- 
plained by  the  fact  that  the  bruise  results  in  a  cir- 
cumscribed lowering  of  the  vitality  of  the  tissues, 
and  any  germs  ca]>able  o-f  exciting  inflammation 
which  may  be  i>resent  in  the  circulatory  oi-  lymi)hatic 
channels  in  this  locality,  have  an  easy  prey,  the  nor- 
mal resistance  to  germ  action  being  overcome  by  the 
lessened  vitality  caused  l»y  the  bruise. 

The  treatment  of  all  contused,  lacerated,  and  punc- 
tured wounds  belongs  strictly  to  antiseptic  and  not 
aseptic,  surgery. 


rUNOTUUFCI)    VVOIINHS  OF   'I'llK    I'.KAIN. 


(UlAi'TEi;  \'l. 
rUNCrURICI)  WOUiNDH  OF  THE  BKAIX. 

Clinically,  tlicMc;  injurioB  seldom  occur  except 
through  the  orbital  plate  of  the  frontal  bone.  A  very 
few  rare  cases  have  bo(Mi  reporlcd  of  11ie  pniirhii-ing 
iustrunienl  enU'riug'  (hrongh  the  nosti'ils.  An  instru- 
ment may  be  driven  through  the  skull  at  any  part 
and  wound  the  brain.  A  considerable  variety  of  in- 
struments have  been  known  to  penetrate  the  brain  by 
way  of  the  thin  orbital  plate  of  the  frontal  bone,  the 
most  common  having  been  umbrella  sticks,  canes, 
pieces  ol  wood,  narrow-bladed  instruments  of  war- 
fare, etc.  The  eye  not  uncommonly  escax>es  injury 
when  the  entering  instrument  fractures  the  orbital 
plate  near  the  superior  orbital  fissure.  In  such  cases, 
the  wound  first  passes  through  the  upper  eyelid.  A 
part  of  the  imncturing  instrument  may  remain  in  the 
brain.  The  injury  to  the  brain  is  usually  confined  to 
the  frontal  lobes,  but  may  involve  other  parts.  If 
the  brain  is  punctured  through  the  optic  foramen,  the 
eye  is  almost  certainly  injured,  and  the  optic  nerve 
is  necessarily  crushed  or  divided,  unless,  perchance, 
the  puncturing  instrument  is  of  very  small  diameter, 
like  a  hatpin.  Besides  any  injury  to  the  eye  which 
may  complicate  these  accidents,  the  main  danger  lies 
in  the  brain  lesion.  Not  so  much,  usually,  the  im- 
mediate results  from  destruction  of  brain  tissue,  as 
the  secondary  inflammatory  processes  likely  to  arise 
as  the  effect  of  the  injury.  Hemori'ha.ge  may  be  suf- 
ficient to  produce  dangerous  pressure  symptoms,  but 
this  will  hardly  occur  unless  the  injury  is  through 
the  floor  of  the  orbit  tow^ards  the  vessels  at  the  base 
of  the  brain. 

The  treatment  of  these  injuries  should  be  directed 
towards  an  exposure  of  the  injured  parts  sufficiently 
extensive  to  enable  the  surgeon  to  examine  carefully 
for  the  presence  of  a  foreign  body  when  from  the  his- 


34  MODKRX    TREAIMKNT    OF    WOUNDS. 

toi'jT  of  tlir  i;is(.'  siuli  a  body  may  liave  remaiiieil  in 
the  wouiul.  The  surjreou  slionld  not  limit  his  inter- 
ference until  he  has  cleared  a  i)assag;e  for  careful  irri- 
{^ation  and  draina}i;e  of  the  injured  brain.  Allhouji^h 
it  may  be  necessary  to  boldly  open  up  the  skull  iu 
linni  of  and  above  the  track  of  the  wtuind.  usually  it 
will  suflice  if,  after  shavin*;'  the  eyebrow  and  using 
the  usual  antiseptic  preeatitions.  the  orbital  plale 
of  the  frontal  bone  is  exposed  by  making;  a  free  curved 
incision  along  the  upi>er  (nlge  of  the  orbit  down  to 
the  bone,  separating  the  loose,  celltilar  tissue,  and 
depressing  the  globe  with  a  small  Hat  retractor. 
By  this  means  sullicient  spaei-  will  be  secured  for  the 
exposure  of  the  wound.  With  small  chisels  the  open- 
ing through  the  bone  is  enlarged  sufficiently  to  ex- 
plore the  wound  and  provide  for  drainage.  The 
accom])anying  ]»hotograph  was  taken  from  a  child 
that  had  fallen  upon  a  rusty,  dirty  buttonhook  with 
which  it  had  been  playing.  The  hook  end  of  tlie  in- 
strument had  passed  through  the  upper  lid,  the  or- 
bital plate  of  the  frontal  bone,  and  into  the  brain. 
The  hook  had  in  some  manner  rotated  so  that  it  was 
necessary  to  remove  considerable  bone  before  it  was 
extracted.  The  writer  followed  the  practice  just  rec- 
ommended and  recovei'y  was  entirely  satisfactory. 
Should  the  brain  bo  punctured  through  the  optic  fora- 
men, the  eyeball  must  be  removed  to  admit  of  proper 
exploration  and  drainage.  Tn  such  a  case,  even  if 
the  globe  of  the  eye  is  not  injured,  the  optic  nei've 
probably  is,  and  in  any  case  it  is  better  to  sacrifice 
the  eye  than  to  invite  secondary  inflammatory  condi- 
tions in  the  orbit,  and  maybe  in  the  brain.  A  good 
general  rule  would  be  that  in  all  cases,  the  bottom  of 
the  wound  should  be  explored  and  drained  by  the 
most  direct  route,  preserving  the  integrity  of  an  uniu 
jnred  eyeball  when  possible.  Tf  the  eyeball  is 
wounded  and  ])robably  infeoted  it  should  be  removed. 
The  inflammatory  swelling  of  the  loose  connective 
tissues  of  the  orbit  is  a  source  of  great  danger.  The 
swelling  interferes  with  drainage,  and  inflammation 
may  pass  from  infected  orbilnl  tissues  along  the  track 


I'l.ATK   II. 


Pmu-tured  wound  of  the  brain  through  the  orbital 
phxto  of  the  frontal  bone.  (From  a  patient  in 
tl\e  riarkson  Hospital.) 


I/UNOTUItl'M)   WOIJNI>S   <)['   Till;    IIUAIN.  ...) 

of  the  wound  to  the  brain.  Wlicn  praclical>l(',  I  h' 
counHcl  and  aKHislance  of  an  cxporl  o(;culiHt  hIiouM 
always  bo  soii^^bj  in  llif  Ircaliiiciil  of  Ihesc  compli- 
cated injuries. 

In  those  rare  wounds  of  llic  brain  lliroii^h  I  lie  nos- 
trils tlie  base  of  tlie  bi'ain  sliould  lie  frecl.v  exposed 
hy  inalving  an  opening  ihrongli  the  fronlal  lionc. 
Mo»t  painstakin};'  antisepsis  most  be  employed  so  as 
to  limit  probable  infection  derived  from  llie  nasal 
<javity. 


36         MODERN  TREATMENT  OF  WOUNDS. 


CHAPTER  VII. 

ri;M;ri;ATiNU  wounds  of  the  chics r. 

Eveu  iu  civil  practice  a  large  ijercentage  oi  wouuds 
of  the  chest  ai*e  caused  by  bullets,  j-et  not  a  few  are 
made  by  shai-jt-poiutcd  instruments  of  various  kinds. 
Tho  general  i»rinciples  inv(^lved  in  the  diagnosis  and 
treatment  are  essentially  the  same.  We  can  best 
classify  punctuiing  wounds  of  the  chest  into  those 
which  })ass  through  the  chest  wall  into  the  pleural 
cavity,  and  those  wliich,  after  ])eneli-ating  I  he  costal 
pleura,  wound  (he  lung,  pericardium,  heart,  or  large 
vessels.  The  fii'st  variety  is  not  usually  immediately 
serious,  but  n\ay  become  so;  the  dangers  are  hemor- 
rhage from  the  wounding  of  an  intercostal  vessel  or 
a  secondary  septic  empyema.  Rai'e  cases  have  been 
recorded  of  hernia  of  the  lung.  When  the  wound 
is  low  down,  the  diaphragm  may  be  divided  and  omen- 
tum or  intestine  pass  upwards  tlirough  the  wound  in 
the  diaphragm. 

Wounds  of  the  lung  are  very  dangerous  when  the 
inflicting  instrument,  if  a  bullet,  is  a  large  one  and 
passes  into  or  througli  the  lung  near  its  base.  The 
same  rule  applies  to  wounds  from  Icnivcs  and  other 
sharp-pointed  instruments.  Small  wounds  into  or 
through  the  thin  edge  of  the  lung  are  not  very  dan- 
gerous. 

Wounds  of  the  heart  are  usually  immediately  fatal. 
Wounds  of  the  pericardium,  although  exceedingly 
serious,  are  recoverable.  Penetrating  wounds  of  the 
mediastinum  which  are  not  immediately  fatal  from 
hemorrhage  will  become  most  serious  should  infec- 
tion occur. 

The  diagnosis  of  penetrating  wounds  of  the  chest 
depends  mostly  upon  a  good  knowledge  of  physical 
diagnosis  and  the  meaning  of  the  symptoms  of  shock 
and  hemorrhage.  If  after  antiseptic  precautions  a 
sterile  probe  enters  the  pleura,  the  wound  is  a  pene- 


['KNMTJtATI.N'fi    WOUNDS   Ol'     I'lli;    <  iUOST.  'M 

tratinjjf  oiks  If  Iho  inflicting  insi rumen t  is  small,  ajid 
the  wound  ol  entranco  over  and  itw  Hn]}j)OHQ<l  diroction 
towards  tlio  tliin  portions  of  the  Innjjc  5>nd  away  from 
tho  lieart  and  clu^st  (;onter,  the  pi-csninpiion  is  that 
comparatively  little  danger  is  to  be  anticipated,  es- 
pecially if  all  symptoms  of  hemorrhage  are  absent. 

H!/iiif)foms  of  JTcviorrhage. — The  raising  of  bloody 
sputa  proves  pretty  well  that  the  lung  is  injured. 
The  more  or  less  rapid  accumulation  of  fluid  in  the 
pleural  cavity  indicated  by  the  physical  signs  of 
hydrothorax  or  hydropneumothorax,  accompanied  by 
the  usual  general  symptoms  of  internal  hemorrhage, 
proves  that  blood  is  accumulating  in  the  pleural 
cavity.  If  the  force,  size,  and  direction  of  the  bullet 
or  cutting  tool  indicate  a  lung  injury,  especially  if 
some  blood,  even  a  little,  is  coughed  up,  the  source 
of  hemorrhage  into  the  pleura  is  probably  from  a 
wound  in  the  lung.  The  pneumothorax  may  come 
from  inspired  air  or  from  air  being  sucked  into  the 
chest  through  the  wound  in  the  chest.  Hemorrhage 
from  the  wound,  if  bright  red  and  spurting  or  active, 
comes  from  an  intercostal  or  internal  mammary  ar- 
tery; if  dark  and  flowing  in  character,  it  is  probably 
from  the  lung.  Emph^'sema,  when  present,  usually 
comes  from  air  which  has  been  inspired.  The  air  may 
have  come  from  without  into  the  wound.  The  greater 
the  shock  the  more  serious  the  injury,  especially  if  the 
temperature  is  subnormal. 

In  a  recent  case  of  the  writer's  where  there  were 
two  wounds  made  by  a  large  bullet,  the  wounds  of 
entrance  and  exit  being  five  inches  apart,  he  was  able 
to  demonstrate  that  the  lung  was  not  injured.  This 
proves  that  in  rare  instances  it  is  possible  for  a  wound 
of  this  character  to  exist  without  perforation  or  even 
grazing  of  the  lung. 

Wounds  of  Perkardium  and  Heart. — The  differential 
diagnosis  between  wounds  of  the  pericardium  and 
wounds  of  the  heart  may  be  insurmountable.  In  both 
there  is  apt  to  be  sharp  pain,  more  intense  if  the  heart 
is  injured.  Dyspnea  is  more  marked  if  the  heart  is 
injured  and  the  physical  signs  of  the  presence  of  fluid 


oS  MODERN    TUKAT.MKNT    Ol'    WOUNDS. 

ill  ihe  iH'ricaitliuiii  ;irc  pi-cscin  aliimsi  iiiiiiKMruurly 
and  iiicicast'  ia|ti(lly. 

In  jn'i-icarilial  wonnds  ihc  cardiac  syncoin'  is  not  so 
j^rcat,  lu'causc  ilicic  is  less  rapid  accuinulation  of 
blood  in  the  sac.  A  wonnd  of  [he  lu-ai-t  may  of 
itsolf  cause  death  almost  immediately  or  in  a  short 
while,  hut  when  death  is  delayed  a  few  hours  it  is 
usually  due  in  great  i>art  to  overdistention  of  the 
pericardium  with  blood.  Death  may  result  from  sec- 
ondary inflammation.  In  wounds  of  the  ])ericardium 
death  is  due  to  the  same  causes. 

The  trcntiiicnt  of  penetrating  wounds  of  the  chest 
involving  the  chest  wall  and  lung  is  usually  best 
limited  to  the  internal  administration  of  opium  and 
the  local  ai>]>lica1iou  of  a  primary  anlise])tic  dressing. 
If  the  chest  wall  is  at  all  lacerated,  hemorrhage  should 
be  controlled,  all  loose  fragments  of  ribs  and  any  for- 
eign body  discoverable  removed,  and  drainage  pro- 
vided. If  a  ball  has  passed  through  the  chest  and 
lodged  under  the  skin,  it  can  be  removed,  but  it  is 
folly  to  probe  or  explore  with  the  finger  in  order  to 
discover  a  bullet  in  the  lung.  There  is  great  danger 
of  setting  up  hemorrhage  or  inflammation.  Sec- 
ondary operations  within  the  pleural  cavity,  or  even 
the  lung,  are  safer  than  too  active  interference  in 
])rimarily  dangerous  injuries.  Unless  dyspnea  points 
towards  impending  death  from  the  loss  of  blood  and 
its  accumulation  in  the  pleural  cavity,  surgical  inter- 
ference is  not  indicated.  Absolute  rest  should  be  en- 
joined, ice  applied  to  the  chest,  and  opium  and  ergot 
given  internally.  If  the  source  of  the  hemorrhage 
is  thought  to  be  an  intercostal  artery  or  the  internal 
mammary  artery  (we  can  tell  something  about  this 
from  the  relation  of  the  wound  to  the  ribs  and  its 
l)Osition  in  the  chest),  it  should  be  exposed  and  tied. 

Aspiration  or  incision  for  the  evacuation  of  blood 
from  the  i)leural  cavity  may  be  practiced  if  suffoca- 
tion threatens  death,  but  in  these  cases  death  may 
follow  from  a  continuance  of  the  bleeding.  Under 
such  conditions  there  may  remain  nothing  to  ])iomise 
hope  other  than  a  bold  resection  of  a  suflBcieul  nnudier 


PHNPJTKATINO    WOtlNDH   01'   TlIK  (;UKST.  I'D 

of  ribs  tO'  allow  oi:  Iho  puckiii}^  into  Iho  pleura  and 
against  the  lung  of  a  sufTicienI;  quantity  of  nterile 
gauze  to  control  Uio  hcniorrhjigo. 

rneumotlioi'ax    and    <Mnpyeina    resulting    fi-oni    in 
fected  blood  accumulations  are  treated  upon  general 
principles,  viz.,  the  former  may  be  aspirated,  the  lat- 
ter can  only  be  treated  successfully  by  incision  and 
drainage. 

A  wound  of  the  heart  had  better  be  left  to  nature. 
She  sometimes  brings  about  recovery.  These  wounds 
have  been  dealt  with  successfully.  The  p<3ricardiumi 
is  exposed  by  either  an  osteoplastic  resection  of  the 
ribs  or  a  permanent  resection.  The  pericardium  is 
then  incised  and  the  wound  in  the  heart  repaired  by 
suture.  Drainage  must  be  provided  for  accumula- 
tions within  the  pericardium.  If  a  case  of  wound 
of  the  heart  or  pericardium,  or  both  perhaps,  threaten 
death  from  blood  pressure  within  the  pericardium, 
the  sac  ought  to  be  aspirated,  or  even  drained. 

Hernia  of  tlie  Lung. — A  hernia  of  the  lung  following 
a  wound  of  the  chest  should  be  reduced  and  the  w^ound 
closed  by  suture  and  supported  by  suitable  dressings. 
Should  the  diaphragm  be  wounded,  a  complication  of 
a  penetrating  wound  of  the  chest  and  a  protrusion  of 
omentum  or  bowel  into  the  chest  follow,  the  condition 
might  be  recognized  by  physical  signs,  and  the  symp- 
toms of  obstruction  of  the  bowels.  A  free  opening 
into  the  chest  should  be  made  in  a  suspected  case  of 
this  kind,  and  if  a  hernia  is  discovered  it  should  be 
reduced  and  the  wound  in  the  diaphragm  sewed  up. 

Penetrating  wounds  of  the  mediastinum  require  the 
most  T)ainstalvin2:  antiseptic  treatment. 


HI  Mtiiii;i;.N  ■i"iM:Ar.Mi;\r  di'   woinks. 


CllAl'TEK  \  111. 

'I'lIKAIWlKNT    OF    I.\(1SI:J)    AM)    IH  NC  Jl   KKD    WOINDS 
OF    Till-:    Al'.DOMFN. 

The  gi'iu'ral  iiriiiciiilcs  ol'  sui'^^cry  involved  in  tlie 
rreatmoiit  oi"  peuetratinj^  gunshot  avoiiikIs  oI  iIk-  ab- 
doiiu'u  apply  einiall.v  to  laeci-atcd,  iuciscd,  and  piuu- 
tuied  wounds  of  the  abdomen,  produced  bj'  blunt  or 
iriTgiilaily  siiaprd  liodics  and  by  those  of  bioad  or 
narrow  keen-edged  inslrunients. 

All  non-penetrating  wounds  of  the  abdominal  wall 
should  be  treated  upon  the  same  principles  as  wounds 
of  the  same  kind  in  other  parts  of  the  body — i)articu- 
lar  attention  being  paid  to  accurate  approximation 
of  the  separate  muscles  and  fasciie  by  buried  sutures. 
AA'hen  doubt  exists  in  the  mind  of  the  surgeon  as  to 
whether  or  no  the  peritoneum  lias  been  o])encd,  digital 
and  instrumental  exploration — with,  if  necessary, 
careful  enlargement  of  the  wound — will  usually  de- 
cide this  jioint;  or,  being  still  unsettled,  the  abdomen 
may  be  ojK'ued  in  the  median  line  and  the  jjciitoneal 
area  of  the  abdominal  wall  beneath  the  wound  exam- 
ined by  sight  and  touch. 

If  inspection  or  the  examinations  just  indicated 
demonstrates  that  the  peritoneum  has  been  oi)ened, 
the  line  of  treatment  to  be  followed  is  clear  and  posi- 
1  IXC.  Those  in  which  there  may  be  greater  or  less  pro- 
liu-;lon  of  omentum  and  intestines,  one  or  both,  should 
be  carefully  washed  with  warm  sterilized  water,  any 
bleeding  nx^seiileiie  vessels  tied,  and  the  wounds 
stit(  lied.  Then  the  ])rotiuding  ])arts  should  be  care- 
fully washed  again  and  returned  into  llie  cavity  and 
ihe  abdominal  walls  sutured.  This  treatment  is  abso- 
luiely  necessary  to  save  life,  and  may  be  don  '  by  any 
jdiysician.  In  all  cases,  whenever  it  is  uncertain  what 
the  extent  of  the  injuiy  may  be,  whether  or  no  any  a  is- 
cus  is  wounded,  th<*  abdomen  should  be  opened,  usu- 
a11\-  iTi  tlie  median  line,  and  a  careful  seai-ch  made  for 


I,\('1SI0I»    AXI)    rilXC'I'lIKIOI)    WOI  :\hS   (tf    A  111  •<  >.\1  i;.\  .         11 

iiijui-i<"H,  and,  if  roiiiHl,  llicy  slioiild  Ik;  i-(*j>;nr<;(l  \>y  lli«i 
simplest  and  mosl  rapid  methods  coii»iK((!nt  with  ac- 
curacy. It  is  O'fteiilimcH  im|K)ssil)Ie  lo  tell  if  a  viscus 
lias  been  wound(Hl,  no  mailer  what  the  Hhai)e  of  the 
offending  instruments  or  the  locality  of  the  wound 
where  it  was  forced  through  the  abdominal  walls. 
There  may  be  little  or  no  shock  or  symptoms  of  hem- 
orrhage, and  yet  extensive  trauma  exist.  The;  many 
differentiating  signs  between  involvement  and  non- 
involvement  of  the  various  abdominal  viscera  after 
penetrating  v^ounds  of  the  abdomen  are  valuable,  but 
all  are  unreliable  and  not  absolutely  to  be  depended 
upon,  and  there  are  no  means,  short  of  abdominal  sec- 
tion, by  which  this  can  be  positively  determined. 
Stab  wounds  are  more  likely  to  be  follo-wed  by  hemor- 
rhage than  bullet  w^ounds;  yet  the  instrument  does 
not  so  often  injure  the  bowels,  especially  if  they  are 
comparatively  empty.  The  swift-moving  bullet  en- 
ters the  intestine  whether  distended  or  empty;  thi 
cutting,  slowly  moving  instruments  may  simply  push 
them  aside.  The  use  of  hydrogen  gas,  as  recom- 
mended by  Senn,  is  perhaps  the  most  trustworthy 
method  of  determining  whether  or  no  the  stomach  or 
intestine  bas  been  wounded,  and  also  of  determining 
whether  or  no  all  of  the  openings  possibly  made  into 
the  viscera  have  been  sutured.  The  employment  of 
hydrogen  gas  in  these  cases  is  more  scientific  than 
practical,  and  when  shock  predominates  its  use  is 
contraindicated  as  consuming  too  much  time. 

Prog)wsis.* — 'The  most  recent  statistics  of  the  results 
of  operations  for  stab  wounds  of  the  abdomen  (Gas- 
ton's tables)  contain  twenty-eight  cases  in  which  ab- 
dominal section  was  done,  with  sixteen  recoveries;  of 
this  number,  nineteen  had  wounds  involving  one  or 
more  of  the  viscera  and  of  these  ten  recovered  and  nine 
died.  If  it  is  known  that  a  cutting  instrument  has  en- 
tered the  abdomen,  the  wounding  of  the  viscera  is  to 
be  assumed,  yet  '^penetrating  wounds  of  the  abdomen 

*  The  writer  recently  operated  upon  a  young  man  for  a  stab  wound  of 
the  abdomen,  who  recovered  in  spite  of  the  fact  that  leakage  had  oc- 
curred from  two  wounds  of  the  transverse  colon.  The  operation  was 
done  within  two  hours  after  the  injury,  hence  the  recovery. 


il*  ilOUKli.N    TKEATMBNT    OF    WOUNDS. 

wiihuiil  si'i-ious  vist'(-*i-al  injuries  aiid  without  the  pres- 
euce  of  a.  septic  loreij;u  body  in  the  abdomiual  cavity 
are  fretiueiitly  followed  by  recovery  without  resort 
to  intra-abdominal  treatment."  In  fact,  in  about  10 
per  cent,  of  all  pi'nelraiiujjc  wounds  of  the  alulonien 
the  viscera  escape  injury.  This  well-known  truth  that 
very  many  persons  whose  abdomens  have  been  jjunc- 
tured  by  jagjred,  blunt,  or  sharp-pointed  instruments 
have  gotten  well  without  snrjiical  interference  brings 
us  to  what  may  b<^  considered  the  most  important 
part  of  this  subject,  and  that  is:  When  it  is  uncertain 
what  the  extent  of  the  injury  may  be,  whether  or  no 
any  viscus  is  wounded,  we  should  resen^e  explorative 
measures  for  the  determination  and  the  repair  of  such 
injuries  to  the  hands  of  a  trained  modern  surgeon  of 
experience  in  the  practical  workings  of  aseptic  sur- 
gery. The  services  of  such  a  man  can  always  be  had 
nowadays,  or,  circumstances  possibly  preventing,  a 
young  man  who  has  been  taught  practically  how  to 
do  intestinal  surgery  upon  the  human  cadaver  and 
liring  animals,  and  has  acted  as  assistant  in  hospitals 
or  private  practice  to  men  who  do  clean  work  in  the 
strictest  sense,  should  be  called.  The  management 
of  these  grave  cases  should  not  be  trusted  to  any  oth- 
ers. It  is  rather  amusing  to  read  from  time  to  time 
about  abdominal  suigery  upon  the  battlefield.  Of 
course,  these  effusions  come  from  men  who  never  saw 
a  battle,  except  in  prose,  verse,  or  upon  canvas.  As 
the  perfection  of  modern  war  implements  has  not  yet 
done  away  with  the  saber  and  bayonet,  it  is  to  be  ex- 
pected that  incised  and  punctured  wounds  of  the 
abdomen  will  be  inflicted  in  future  wars,  and  perhaps 
some  of  them  come  into  our  hands  for  treatment.  For 
this  reason  the  writer  ventures  to  call  attention  to 
the  opinions  of  his  preceptor,  one  of  our  leading  au- 
thorities in  such  matters  Dr.  Wm  H.  Forwood, 
United  States  Army  Professor  of  Surgery  in  the 
Army  Medical  School.  The  opinions  of  the  doctor 
refer  more  especially  to  gunshot  wounds,  but  apply 
to  the  class  under  considei'ation  just  as  well.  He 
says  in  substance: 


IN(HKI*]I)    AND    I'lIXO'l'lIIlIOl)    W<MJNI)S   OF    A  l!I>0.\I  i; N.        l.{ 

''Jiapar()4()in.y  I'ov  j.>,imsliol  wounds  (>{'  I.Ik;  ubdoiuijial 
viscera,  unlike  many  other  operations  in  military  Hur- 
gery,  will  always  be  greatly  restriclod  in  ils  njtjdica- 
tion  and  usefulness  by  the  very  exiicling  cojiditiijns 
necessary  to  success.  Wounds  id  the;  viscera  do  not 
admit  of  delay.  There  is  no  way  to  prevent,  sepsis, 
as  in  external  wounds.  The  time  that  may  elajise 
before  an  operation  must  be  done  is  limited  to  from 
three  to  five  hours,  after  which  the  chances  of  suc- 
cess diminish  very  rapidly. 

''The  operation  must  be  done  at  the  hospital,  in  a 
warm,  quiet  room,  protected  from  wind  and  dust,  with 
good  lights,  competent  assistants,  plenty  of  time,  and 
the  advantage  of  the  strictest  antiseptic  precautions. 
Very  exceptional  qualifications  are  demanded. of  the 
surgeon.  None  but  those  having  skill  and  special 
training  in  this  line  and  who  have  had  considerable 
experience  at  least  on  the  cadaver  and  on  living  ani- 
mals should  dare  undertake  it.  The  mortality  from 
laparotomy  for  gunshot  and  stab  wounds  of  the  in- 
testines done  by  inexperienced  operators  will  be  much 
greater  than  that  under  the  expectant  plan  of  treat- 
ment. Except  in  siege  operations,  the  hospitals  will 
very  rarely  be  established  in  time  to  offer  the  benefit 
of  this  operation  to  those  wounded  in  the  early  part 
of  an  engagement.  Very  few  of  the  severely 
wounded  will  be  able  to  reach  the  hospital  under  or- 
dinary circumstances  within  five  hours  after  the  re- 
ceipt of  their  injuries.  Men  with  penetrating  wounds 
of  the  abdomen  suffer  from  shock  and  hemorrhage, 
and  often  have  to  remain  for  a  time  on  the  field,  and 
they  usually  have  to  be  carried  long  distances  on  lit- 
ters. Such  cases  are  brought  to  the  hospital  in  the 
evening,  or  during  the  night,  when  the  difficulty  of 
operation  is  increased  by  want  of  proper  light,  or 
more  frequently  not  until  the  following  day.  when  it 
is  too  late.  An  operator  with  requisite  skill  and  ex- 
perience will  rarely  be  available,  and  when  there 
are  many  wounded,  the  services  of  two  or  three  of  the 
best  surgeons  for  an  hour  or  two  of  precious  time  can 
seldom  be  given  to  the  doubtful  benefit  of  one  among 


4  !  MODKIt.N     riaiAT.MENT    oK    WulNDS. 

a  uuiiilifr  of  lilt  11  ui-<,M'iitly  iict'din^-  assis(aiK-o.  Bat- 
tk's-  ii'sull  ill  ili'fcat  as  well  as  in  vii-tory  on  ono  side 
or  (he  oilior.  and  among  the  wounded  prisoners  llio 
benelit  of  laparotomy  will  hardly  be  realized,  al- 
thouffh  some  autemortem  abdominal  sections  may  be 
made  by  well-meaniu}?  surjreons  with  more  zeal  than 
discretion.  On  the  whole,  the  outlook  for  future 
operative  interferenee  in  cases  of  penetratinj^  wounds 
of  the  viscera  on  the  battlefield  is  not  very  promising;. 
But  still  there  will  be  exceptional  cases  and  especially 
favorable  circumstances  where  this  ]>rocedure  may 
become  practicable." 

Technique. — Fine  iron-dyed  silk  and  ordinary  round 
sewing  needles  are  the  best  material  for  closing 
wounds  of  the  intestines,  and  if  the  wound  is  over  one 
centimeter  in  lenjith  we  can  use  the  continuous  Lem 
bert  sutures,  otherwise  the  interrupted.  If  there  is  no 
hurry,  it  is  best  to  use  a  double  row  of  sutures.  If  the 
trauma  demands  excision  of  any  part  of  the  gut,  and  if 
there  is  no  great  urgency,  end  to  end  anastomosis  by 
suture  is  a  good  method, — if  the  case  is  urgent  a  Mur- 
phy button  may  be  employed.  Blood-vessels  may  be 
tied  with  silk  or  catgut.  Wounds  of  the  liver  should  be 
sutured,  or  the  wound  of  entrance  may  be  tanii)oned, 
or  if  a  through  and  through  wound,  an  instrument 
such  as  a  catheter  may  be  passed  through  its  track 
and  a  tampon  of  gauze  drawn  after  it.  Wounds  of 
the  spleen  may  be  sutured  or  the  cut  sui-face^s  com- 
pressed by  a  figure  of  8  ligature  drawn  over  the  pro- 
truding ends  of  a  threaded  needle,  passed  at  right 
angles  across  the  w^ound.  or  the  gland  may  be  re- 
moved. Wounds  of  the  kidneys  should  be  drained 
by  gauze  packing  through  an  incision  in  the  loin,  or 
it  may  be  best  to  do  a  nephrectomy.  Wounds  of  the 
bladder  should  be  sutured  and  the  abdominal  cavity 
flushed  and  drained;  indeed,  flushing  and  draining  of 
the  abdomen  is  indicated  after  all  ojterations  for  the 
repair  of  traumatisms  of  its  contents. 


i.N'ruA-Ai;r>()Mi.\Ai-  lkhioxs,  45 


CHAPTER  IX. 

TIIK  'rillOATMl':NT  OK  IN  TUA-A  I'.DOM  IXAf.  LICSIO.NS  FOL- 
LOWING CONTUSIONS  OF  THE  AJ5D0M[NAL  WALLS. 

Falls,  kicks,  blows  upon  the  abdomen,  and  \\u-  [tas- 
sage  over  the  abdomen  of  wagons,  carts,  etc.,  may 
result  in  simple  contusion  of  the  skin  and  muscles 
overlying  the  abdominal  contents  or  else  in  injuries  of 
the  liver,  spleen,  kidneys,  stomach,  intestines,  omen- 
tum, or  bladder.  Sometimes  more  than  one  of  these 
is  injured  at  the  same  time. 

Rupture  of  the  ^pJcen  <iiifl  Lirer. — The  diagnosis  of  a 
rupture  of  the  spleen  or  liver,  except  for  the  symp- 
toms of  intra-abdominal  hemorrhage  and  shock,  is 
extremel}'  uncertain.  The  location  of  the  contusion, 
and  the  direction  of  the  contusing  force,  taken  to- 
gether with  some  abdominal  rigidity  and  special  ten- 
derness, localized  over  the  area  nearest  the  organ,  is 
of  value  in  establishing  the  diagnosis  of  rupture,  pro- 
vided there  are  symptoms  of  internal  hemorrhage. 
In  the  absence  of  symptoms  of  hemorrhage  they  indi- 
cate simple  contusion  of  these  organs. 

Rulpture  of  the  kidney  is  a  very  common  accident 
and  is  usually  recognized  by  shock,  localized  pain,  and 
the  passage  of  bloody  urine.  A  localized  tumor  will 
not  form  if  the  rupture  occurs  directly  through  the 
peritoneal  investment  into  the  peritoneal  cavity.  If 
the  rupture  occurs  so  that  the  blood  accumulates  in 
the  loose  cellular  tissue  surrounding  the  kidney,  a 
tumor  forms  rapidly,  presenting  first  in  the  posterior 
ileo-costal  space,  enlarging  downwards,  forwards,  and 
inwards.  Urine  may  also  extra vasate  in  the  same 
directions  and  even  towards  the  surface.  Cases  in 
point: 

I. — A  driver  of  a  patrol  wagon  was  thrown  off  his 
seat  and  the  wheel  of  this  heavy  wagon  passed  di- 
rectly across  the  upper  part  of  the  abdomen.     Within 


4(>  Mor>i:uN  trkatmiont  ok  wol.nus. 

six  hours,  besides  the  sviuplums  of  shock,  pain,  tender 
abdomen,  and  bloody  urine,  a  tunioi-  was  easily  dis- 
citvei-able  in  raili  loin.  These  swellings  lasted  sev- 
eral weeks.  Al'tei-  ihe  lirst  twelve  hours  there  was  a 
gradual  rise  ot  leniperalure,  and  this  ranged  from 
100°  F.  to  103°  F.  for  some  days.  The  abdomen  was 
distended  and  tender.  There  was  an  absence  of  some 
of  the  cardinal  symptoms  of  peritonitis,  especially 
those  ot  a  sejitir  character;  however,  we  were  some- 
what puzzled,  and  it  was  ditiicult  to  weigh  the  evi- 
dence. Later  a  ttuctuatiug  swelling  apjteared  in  the 
back  on  a  level  with  the  kidney  areas.  The  greatest 
prominence  of  this  tumor  was  in  the  middle  line.  I 
aspirated  the  swelling  in  the  back  and  submitted  the 
fluid  to  Dr.  \V.  K.  Lavender  for  examination.  He 
reported: 

"Specimen — Hpecihc  gravity  1015;  reatiion  alka- 
line; color,  yellow-reddish  (V.  Vogelj. 

"Centrifugal  sedimentation. — ^^^edinient  blood  red; 
microscopical;  (1)  large  number  of  i*ed  blood  corpus- 
cles in  rouleaux,  some  crenated,  others  distorted 
(poikilocytosis);  (2)  quite  a  number  of  leucocytes,  poly- 
niori)honuclear  i)rincij)ally ;  {'.\)  a  number  of  cylin- 
droids.  A  quantity  of  amorphous  urate  crystals.  K. 
B,  C.  and  cylindroids,  with  an  occasional  hyaline  east, 
all  of  which  are  massed  together  by  action  of  cen- 
trifuge. 

"Diagnosis — ^Fluid  ])rin(ipally  composed  of  blood 
and  serum  with  decided  presence  of  urine  in  speci- 
men." 

This  man  recovered  without  suppuration,  although 
his  convalescence  was  tedious. 

IL — A  little  girl,  eight  years  old,  fell,  striking  her 
right  side  against  a  dry-goods  box.  When  seen  a 
few  hours  later  there  was  considerable  shock,  pain, 
and  al^dominal  rigidity.  A  tumor  was  readily  felt  in 
the  right  ileo-costal  space.  At  the  end  of  twenty-four 
liours  the  symptoms  so  simulated  a  commencing  gen- 
eral peritonitis  that  an  incision  was  made  in  the  up- 
l»ei-  (juadrant  to  the  right  of  the  right  rectus  muscle. 
There  was  no  jx-ritonilis  in  spite  of  the  ])ain,  fever 


IXTIIA-AI'.DOMINAL    LIOSIONS.  47 

l()o°  F.,  a.lxlomiiial  (Jisloiilion,  and  Jiiu.scular  ri^idily, 
but  a  large  iiitio-peritoneal  swelling  (hematoma)  waw 
disoloHed  surrounding  (ho  kidney  and  Hoparating  the 
peritoneum  along  i(.s  lines  of  least  resistance.  The 
abdominal  wound  was  sutured  and  an  incision  made 
in  the  loin,  I'rom  which  was  discharged  a  (juantity  of 
blood  and  urine.  A  rent  could  be  felt  in  the  kidney. 
The  wound  was  i)acked  with  sterih*  gauze  to  control 
a  rather  dangerous  hemorrhage.  The  child  recovered, 
although  it  was  about  a  month  before  urine  ceased  to 
escape  through  the  wound. 

When  a  kidney  is  so  lacerated  that  the  hemorrhage 
accumulates  in  its  pelvis  the  tumor  is  usually  small 
and  forms  slowly,  perhaps  requiring  several  days  be- 
fore it  can  be  detected.  In  such  cases  either  the 
amount  of  blood  in  the  urine  is  rather  excessive  or 
because  of  a  blocking  of  the  ureter  by  clots  little  or 
no  blood  is  found  in  the  urine.  When  the  ureter  is 
blocked  or  injured  so  as  to  prevent  the  escape  of 
bloody  urine  into  the  bladder  the  tumor  may  enlarge 
<iuite  rapidly,  being  similar  in  its  action  to  an  acute 
hydronephrosis.  In  one  case  operated  upon  recently 
all  kidney  tissue  was  destroyed  in  twenty-one  days — 
the  tumor  filled  the  right  side  of  the  abdomen,  occu- 
pied the  false  pelvis,  passing  at  the  level  of  the  um- 
bilicus and  below^  into  the  left  half  of  the  abdomen. 
In  this  rare  case  the  ureter  was  also  enlarged,  but  not 
blocked,  there  being  bloody  urine  in  abundance. 
Both  kidnej'  sac  and  ureter  w^ere  removed  and  the 
woman  recovered.  In  another  more  recent  case  a 
similarly  distended,  though  smaller,  kidney  was  in- 
cised and  drained  with  the  hope  of  saving  its  func- 
tional activity, — sufficient  time,  two  weeks,  has  not 
elapsed  to  determine  the  final  result.*  Other  cases 
have  been  observed  in  which  from  the  subjective  and 
objective  symptoms  there  could  be  no  doubt  but  that 
the  kidney  w^as  ruptured,  but  as  a  rule  these  people 
got  well  without  any  surgical  interference.  The 
■writer  has  found  the  Harris  instrument  and  Kelly 

*  This  patient  recovered  wltli  the  functional  activity  of  the  kidney 
preserved. 


4S  M(»i>KRN  ti{i:ai'.mi:m'  of  wot-nds. 

.  cystostdiit'  and  mcit'ial  <a(lictris  of  ^rcai  xaluc  in 
dcttM'ininin.i:'  the  sonitr  of  a  litMuai  uria.  as  well  as 
the  fnnctional  inic^iiiy  of  hoili  Uidncvs. 

Fatal  intraabdominal  lu'niorrliaj^c  may  follow  a 
iniitnrc  of  llu*  kidney,  but  this  is  an  unnsual  icsnlt. 
In  one  of  my  cases  a  kidney  was  torn  loose  from  its 
normal  iiosition.  On  ]»ost-morrem  examination  it  was 
fonnd  in  the  j)elvis  amdioi-ed  merelv  by  its  ui-eter. 
Strange  as  it  may  seem,  this  man  lived  eijilii  hours 
after  the  fall,  forty  feet,  which  caused  the  injury. 
There  were  multii»le  fractures  of  the  extremities  com- 
plicatiug:  the  abdominal  injury. 

Riipfiiir  of  the  SfoniacJi  inid  fiitrstincs. — The  most 
inii»ortant  intra-abdominal  lesion  following  a  contu- 
sion of  the  abdomen  is  a  rupture  of  the  stomach  or  in- 
t(stine,  because  of  the  highly  infectious  nature  of 
their  contents.  I'nless  recognized  almost  immedi- 
ately or  within  a  veiy  few  hours  a  fatal  termination 
is  almost  inevitable.  I  know  of  no  jjosilively  identi- 
fying symptom  of  this  lesion  unless  it  be  (besides 
those  common  to  other  injuries  mentioned)  a  more 
tirnily  contracted  abdominal  wall,  thoracic  breathing, 
early  and  continued  vomiting.  In  case  the  stomach 
is  ruptured  there  may  be  blood  in  the  vomitus.  The 
sym])toms  of  peritonitis  are  tjuite  positive  and  de- 
veloj*  eai'ly.  although  distention  of  the  abd(»men  may 
not  aj^jiear  until  late,  twelve  to  twenty-four  hours. 
The  writer  recalls  one  case  in  which  most  of  the 
symptoms  wei-e  (]uite  latent,  not  making  themselves 
])ositive  until  ilie  third  day.  The  man  died  on  the 
fifth  day.  On  jtost-moi-tem  (^\amination  a  rent  was 
found  in  the  small  bowel  which  had  evidently  been 
incomplete  to  begin  with,  but  gradually  enlarged  so 
as  to  ]>erniit  of  a  general  ])eritoneal  inf(^ction.  in  spite 
of  an  attemi)t  n]»on  the  ])art  of  nattire  to  wall  otT  the 
injured  bowel  by  mearis  of  a  jilastic  exudate.  Ojx'ra 
tion  was  refused. 

Another  <'ase  seen  for  the  lirst  lime  1  wenty-foni* 
hours  aftei-  injury  ])resented  all  of  the  symptoms  of  an 
approaching  fatal  termination,  yet  there  was  little 
distention.     Death    came    six    hours    laier.     On    i>ost- 


rX'rUA-Ar.DOMINAf.   LE8I0NH.  49 

iii(»i-|('iii  cxiiiiiinal  ion,  l)('si<l('S  ;i  iii|»liiic  of  I  In*  ^r<*;il, 
oincutuni  tliere  was  u  complclc  riiplui-c  oT  iIk*  Hiuall 
intestinie,  with  free  leakage  inio  tli<'  jicritoneal  cavity. 

Paj^et  says:  "But  is  (hero  uo  Hi^ii,  vvitliiii  the  HrHt 
Iwclve  or  ( wuiity-fonr  hours  alter  IIh'  injury,  to  tell 
whether  the  inlcstine  is  ruptured?  Poi-haps  (he  most 
trustworthy  signs  are:  (1.)  the  abdominal  wall  kept 
rigid  and  retracted;  at  no  time  soft  or  moving  in  res- 
piration, but  remaining  rigid  and  concave  for  a  day 
or  longer,  and  then  becoming  distended.  {2.)  Per- 
sistent liiccough.  (3.)  No  improvement  in  the  pa- 
tient's general  condition  at:  the  end  of  twenty-four 
hours;  the  initial  shock  was  perhaps  not  very  severe, 
yet  he  does  not  rally  from  it.  (4.)  Some  deep  point  of 
extreme  tenderness.  But  these  signs  may  be  absent 
or  uncertain;  and  Senn's  test  is  not  within  the  reach 
of  everybody,  nor  alwaA's  to  be  trusted.  The  evidence 
of  internal  hemorrhage  is  sometimes  plain  enough — • 
the  rapid  increase  of  weakness,  the  rising  dullness  in 
one  or  both  lateral  abdominal  regions;  but  the  evi- 
dence of  ruptui'ed  intestine  may  be  sought  most  care- 
fully, and  sought  in  vain,  till  the  patient  is  past  saving 
by  operation." 

Retro-'PeritoneuI  RupfKir  of  flic  Infestiue. — This  very 
rare  accident  is  indicated  by  shock,  pain,  early  rise  of 
temperature,  and  the  rather  rapid  formation  of  an 
emphysematous,  purulent,  inflammatory  swelling  in 
either  loin.  This  swelling  may  spread  along  the  lines 
of  least  resistance,  as  any  other  compound  inflamma- 
tory-gravitation abscess. 

Rupture  of  the  Bladder. — When  the  bladder  is  rup- 
tured by  reason  of  a  contusion  of  the  abdominal  wall 
the  determination  of  tlie  character  of  the  injury  is 
nsually  simple.  The  history  of  the  accident — the 
time  intervening  between  the  last  urination  and  the 
time  of  the  accident,  which,  if  from  five  to  eight  hours, 
would  indicate  a  fairly  full  bladder;  and  hence  in  a 
favorable  condition  to  give  away  under  a  traumatism. 

If  the  accident  were  immediately  followed  by  well- 
marked  shock  and  abdominal  pain  most  intense  over 
the  bladder;  if  the  patient  were  able  to  pass  a  small 


50  MOI>i:U\    rUKATMUNT   OF   wou^•D^^. 

(|iiantii.\  «>l'  lilntidv  uriiK',  or  if  upou  inlrodiiciug  a 
raiheUM-  ilu'  sur^t'ou  loiild  romuvc  only  a  lilllc  bloody 
urine,  tlie  coiubiiicd  history  and  lindinjjs  would  prove 
almost  lo  a  certainty  that  the  bladder  had  been  rup- 
tured. The  injection  of  a  measured  ijuantity  of  sterile 
warm  salt  solution  through  a  catheter  into  the  blad- 
der and  lliis  fluid  immediately  allowed  to  How  out  and 
be  measured  will  determine  i)ositi\('ly  whether  or  no 
any,  and  how  much,  of  the  fluid  may  have  escaped 
through  a  rent  in  the  bladder.  If  the  wound  be  intra- 
jterironeal  and  of  large  size,  most  of  the  salt  solution 
will  lia\-e  i)assed  into  the  peritoneal  cavity.  If  the 
^^ound  be  intra{)eritoneal  and  of  small  size,  most  of 
the  solution  will  return  through  the  catheter.  There 
will  be  very  little  pain  when  the  warm  salt  solution 
enters  the  i)erit()neal  cavity.  When  the  wound  is 
extra-peritoneal,  there  will  be  considerable  pain  pro- 
duced by  the  forcing  of  the  fluid  into  the  extra-peri- 
toneal spaces  within  the  pelvis  and  under  and  above 
the  pubes.  If  air  be  injected  by  means  of  a  David- 
son syringe  through  a  catheter,  it  will,  if  the  blad- 
der be  intact,  produce  a  circumscribed  tymi)anitic 
lumor  above  the  pubis.  If  an  intra-peritoneal  ruj)- 
ture  is  present,  the  air  will  enter  the  peritoneal  cavity 
and  its  presence  can  be  determined  by  an  increasing 
tympany.  When  the  rent  is  extra-peritoneal,  the  in- 
jection of  the  air  is  painful,  and  its  presence  outside 
the  peritoneum  can  be  determined  by  emphysema  of 
the  suprapubic  and  pelvic  cellulai-  tissue.  When  the 
w^ound  is  both  intra-  and  extra-peritoneal,  the  symp- 
toms of  intra-peritoneal  rupture  will  predominate,  as 
there  is  little  resistance  offered  to  the  escape  of  the 
ni'inary  secretion  into  the  peritoneum.  Of  course,  if 
the  extra-peritoneal  rupture  is  large  and  the  intra- 
peritoneal rupture  very  small,  the  reveise  will  be  the 
case.  When  a  ru])ture  of  the  bladder  is  both  intra- 
and  extra-peritoneal,  there  is  but  one  wound  (some- 
times stellated),  the  boundary  line  between  intra-  and 
(^xtra-peritoneal  being  the  nearly  horizontal  line  of 
I'cflection  of  the  parietal  peritoneum  onto  the  bladder. 
I'suallv  twentv-four  to  forty-eight   hours  after  an 


IN'I'UA-AI{|J(JM1NAI.   1>I'J.SI(^NS.  51 

-intra-pei'iloiK;;!!  nipliiro  Hyinptoiim  of  pciiionii  is  de- 
velop and  deulli  i'ollowH.  If,  liovvover,  the  uriiK;  and 
ui'iuary  passages  were  normal  prior  to  the  accident 
and  no  infeetiou  is  introduced  by  means  of  a  catheter, 
sterile  urine  will  enter  th(»  peritoneal  cavily  and  there 
will  be  no  i)eritonitis. 

In  one  of  the  writer's  cases  one  gallon  of  urine  and 
some  clots  were  removed  from  the  peritoneal  cavity 
five  days  after  the  accident.  There  was  no  peritonitis. 
Extra-peritoneal  rupture  is  almost  invariably  followed 
by  a  dangerous  su[)purative  cellular  intlammaiion 
involving  the  suprapubic  and  pelvic  retro-peritoneal 
spaces.  Should  the  patient  survive  long  enough  and 
the  inflammatory  products  not  be  evacuated  by  art  or 
nature,  they  will  extend  to  the  anterior  wall  of  the 
abdomen. 

TREATMENT. 

The  few  illustrative  cases  given  have  been  intro- 
duced merely  as  aids  in  building  a  framework  upon 
which  to  construct  a  rational  practice  in  the  medical 
and  surgical  treatment  of  the  class  of  injuries  under 
consideration.  If  the  diagnosis  as  to  the  parts  in- 
volved, and  the  extent  of  injuries  and  their  anatomical 
relationship  to  the  peritoneum,  could  be  positively  es- 
tablished, treatment,  immediate  and  secondary,  would 
involve  little  indecision.  Of  these  things  it  seems 
there  can  never  be  more  than  uncertain  deductions, 
because  the  premises  are  only  relatively  reliable.  Yet 
we  may  formulate  certain  rules  of  practice  in  the  man- 
agement of  cases  of  injury  to  internal  organs  follow^- 
ing  contusions,  etc.,  of  the  abdominal  walls,  but  these 
rules  must  be  subject  to  modification  by  future  knowl- 
edge. 

Liver  and  Spleen. — When  from  the  symptoms  of 
shock,  localized  pain,  and  internal  hemorrhage  it 
appears  that  either  the  liver  or  spleen  have  been  rup- 
tured, no  operation  should  be  done,  unless  the  pro- 
gressive character  of  the  symptoms  of  internal  hemor- 
rhage indicate  a  probably  fatal  ending.  Opium  and 
ergot  can  be  used  with  benefit,  and  the  chest  and  ab- 


O-  MtinKUN    TRKAr.MKNl'    Ol"     \V(U   N1>S. 

(Idiiit'ii  oil  ilii-  side  of  iiijmv  iiiiiiKiliilizcd  by  an  ad 
licsivc  idasici-  splini.  Tlu'  local  usi-  of  icv  may  he 
lHd]diil.  11'  an  alxloininal  section  is  d(>ne,  this  should 
Dot  be  dehiyed  as  a  piiniaiy  or  stH-oudary  proi-eduix? 
licyond  tlio  time  wIumi  a  laxorahlc  tci-mination  may 
be  hoped  for.  Operations  which  in  themselves  are 
serious  should  not  be  undertaken  ujion  moribund  pa- 
tients. To  perform  a.  tracheotomy  upon  a  patient 
about  lo  die  from  sutfoeation  is  j)raisewoii  liy  and  a 
duty.  .\n  abdominal  section  done  upon  a  patieni  in 
lil<('  condition  from  a  j^rave  intra-abdominal  lesion, 
Tlic  a((  urate  repair  of  which,  even  under  rather  fa- 
\-oiabU*  circumstances,  re(|nires  mucli  linie  and 
nianijtulation,  is  a  mistake. 

A  blcedinj;-  mesenteric  artery  can,  if  recojiiii/.ed,  be 
(juickly  controlled.  In  like  manner  a  ruptured  ectopic 
prep:nancy  can  be  managed,  but  staunching  the  hem- 
oirhage  from  a  ruptured  liver  or  s])leen  is  (]uile  a  dif- 
ferent ju-oposiliou.  il.)  The  introduction  of  stitches, 
with  or  without  gauze  packing,  is  indicated  in  rup- 
ture of  the  liver.  (2.)  For  a  like  condition  of  the 
spleen,  the  same  technique  given  for  stab  wounds  of 
tliat  organ  are  lo  be  followed,  viz.,  they  may  be 
sutured  or  the  torn  surfaces  compressed  by  a  figure- 
of-8  ligature  drawn  over  the  protruding  ends  of  a 
threaded  needle  juissed  at  right  angles  across  the 
wounds.  The  abdominal  wound  would  iinder  this 
procedure  have  to  be  treated  on  the  "open""  ])riiiiiple, 
with  gauze  packing  down  to  the  injured  spleen.  (8.) 
Tlie  gland  may  be  removed. 

Kifhivi/. — (1.)  Kapid  inna-i)eriioneal  hemorrhage 
from  a  ruptured  kidney  should  be  treated  by  imme- 
diate resort  to  a  right-sided  abdominal  section,  liga- 
ture of  tlie  renal  vessels  and  removal  of  the  injui'ed 
organ. 

(2.)  Nctro-peritoncal  ruptuir  of  the  kidney  witli  the 
foiination  of  a  tumor  is  usually  best  treated  upon  the 
exj>ectant  i)hin  as  regards  surgical  interfeience.  Er- 
got, opium,  and  turjientine  should  bi'  given  internally. 
Experience  seems  to  show  that  the  bowels  should  be 
kept  quiet,  because  of  the  intimate  relations  of  the 


INTIJA-AI'.DO.MIXAI-    1J;SI().\S.  .").'{ 

colon  l<)  I  lie  UidiicyH.  l)iHr(*^;n<l  ol'  lliis  point  luiH 
been  known  lo  hiin};'  jiboni  ;i  vaniu'Wii-  of  ifii;il  lif?ii- 
oi'i'hagc.     The  local   use  of  ice  is  bcncficijil. 

(y>.)  The  (Icrclopniciit  of  .scpsi.s  Collowin;;  Ji  rcl  ro  peri 
loncal  rupture  of  the  kidney  i(M|uii-eH  a  jiosl-peiitoneal 
incision  for  the  establJHlnnent  of  drainage, 

(4.)  Life-tlircafrnmf/  hrniaturia,  the  rewuit  of  an  injury 
to  a.  kidney,  denitmds  nejdu'ectoniy  by  the  lumbar 
route. 

(5.)  A  coiiipleic  or  jnirtial  riiphin  of  a  ii.ic'cr  should  be 
treated  by  an  attempt  to  repair  ihe  ureter  ilirough  a 
retro-peritoneal  opening.  P^iiling  in  this  a  nephrec- 
tomy should  be  carried  out  by  carrying  the  incision 
upwards. 

(0.)  Rupture  of  a  kklncij,  followed  by  an  accumulating 
hemorrhage  into  its  pelvis,  should  be  treated  (1)  pri- 
marily like  an  extra-peritoneal  rupture;  (2)  an  extra- 
peritoneal incision  into  the  kidney  should  be  made 
for  the  purpose  of  relieving  the  pressure  and  threat- 
ened renal  atrophy,  unless  within  ten  days  or  two 
weeks  there  are  positive  signs  that  the  tumor,  if  large, 
has  ceased  to  increase  and  has  begun  to  decrease  in 
size.  This  practice .  is  warranted  because  in  one  of 
my  cases  complete  destruction  of  all  kidney  tissue  re- 
sulted, from  overdistention,  in  twenty-one  days.  (3.) 
It  may  be  necessary  to  [a)  attempt  to  obliterate  a  de- 
generated kidney  sac  by  an  incision  and  drainage,  or 
(&)  its  complete  extirpation  may  be  advisable  should 
the  patient's  general  condition  warrant  such  an  un- 
dertaking. 

Stomach  and  Intestines. — (1.)  If  the  symptoms,  as  be- 
fore pointed  out,  cause  even  the  suspicion  of  rupture, 
we  should  be  ready,  upon  the  first  w^arning  that  our 
suspicions  had  some  good  foundation,  to  resort  to  an 
immediate  abdominal  section  for  the  repair  of  the 
injury  and  the  cleansing  of  the  contaminated  peri- 
toneal surfaces.  (2.)  Whenever  the  diagnosis  of  rup- 
ture is  probable  or  humanly  sure  no  time  should  be 
wasted  before  operating. 

Bladder. — (1.)  An  intra-peritoneal  rupture  of  the 
bladder  must  be  treated  bv  an  earlv  abdominal  sec- 


54  MODEUN    TUEATMBNT    OF    WOL'NDS. 

lion  lor  I  he  luiipose  of  siM\iii;j;'  U|i  I  lie  woiiikI  in  I  hi' 
bladdiT,  anil  lor  the  cleansiuy,  bv  llioi-ongh  irrij^a- 
tion,  of  llu'  pei'itoni'al  sac.  Drainage  should  be  em- 
ployed if  there  are  evidences  of  peritonitis.  (2.)  Ex- 
tra-peritoneal rupture  requires  a  median  suprainibic, 
extra-peritoneal  cut  for  draiuajj;e.  The  wound  into 
the  bladder  may  be  sutured  in  i)art  with  an  absorbable 
suturing  material,  but  usually  this  is  not  advisable. 
In  every  case  a  rubber  drain  should  pass  into  the  blad- 
der and  gauze  i)acking  lightly  introduced  into  the 
prevesical  sjtace.  If  there  has  been  such  extravasa- 
tion as  not  to  be  relieved  by  a  median  incision  others 
are  demanded  where  they  will  do  the  most  good.  Per- 
fect drainage  must  be  established. 

A  conilnned  intra-  and  crtra-pcritoiwal  rupture  should 
be  treated  by  a  combination  of  the  practice  given 
above. 


HI-IIAINS   AND   OONTriHIOXS   OF  JOINTH.  05 


CHAPTER  X. 

SPEAINS  AND  CONTUSIONS   OF  JOINTS. 

Wounds  of  joints  nre  convoniciilly  divided  into  two 
general  classes:  1.  Siini)le;  lliose  in  wliicli  the  skin 
overlying  the  joint  is  unbroken,  or  if  so,  the  wound 
is  only  superficial  and  does  not  penetrate  the  joint 
proper.  2.  Compound;  when  not  only  is  the  skin 
wounded,  but  the  wound  extends  through  the  tissues 
into  the  joint. 

The  first  class  of  injuries  are  designated  as  sprains 
and  contusions,  and  embrace  almost  all  injuries  not 
accompanied  by  a  permanent  displacement  of  the  ar- 
ticular surface,  or  a  disorganization  or  serious  break- 
ing up  of  the  bones  and  their  cartilages  going  to  form 
the  joint. 

Sprains  result  from  indirect  violence;  the  muscles 
guarding  the  joints  being  relaxed  or  caught  unawares 
by  some  unexpected  act,  as  a  false  step.  Any  violent 
twist  which  results  in  moderate  or  severe  movements 
beyond  the  normal  limitations  of  function  stretches 
or  tears  the  capsule,  synovial  membrane,  and  liga- 
ments to  a  degree  depending  upon  the  violence  ex- 
erted. The  sj'mptoms  of  a  sprain  are  those  common 
to  injuries  in  general,  viz.,  pain,  swelling,  and  inter- 
ference with  function.  Except  in  the  mildest  kind 
of  sprain,  the  pain  is  intense  immediately  upon  re- 
ceipt of  the  injury.  Swelling  occurs  rapidly  and  is 
due  to  the  accumulation  of  synovial  fluid  within  the 
joint  cavity  as  well  as  the  accumulation  of  blood  and 
exudative  fluids  from  the  torn  and  irritated  blood-ves- 
sels without  the  s^movial  sac.  Not  infrequently  the 
synovial  fluid  is  mixed  with  blood.  Swelling  usually 
reaches  its  maximum  during  the  first  twenty-four 
hours.  The  acute  pain  experienced  on  receipt  of  the 
injury  is  gradually  changed  into  numbness,  which, 
however,  is  immediately  replaced  by  agonizing  pain 
upon  any  attempt  at  motion  of  the  joint;  especially  is 

5 


56  MODERN    TREATMENT    OF    WOUNDS. 

this  so  w  lull  ligaments  have  been  toi-u.  In  sui-h  cases 
pain  on  prcssnre  is  most  severe  over  tlic  points  of  in- 
sertion of  torn  ligaments  wliitli  usu.iUv  give  way  at 
these  i)hu'es.  sometimes  strii)[)ing  or  i'liipj)ing  olY  small 
pieces  of  periostenm  or  bone  with  them. 

PrognofilS  is  uncertain,  depending  in  the  main  upon 
proper  recognition  (»f  the  importanee  of  the  injury  and 
an  intelligent  api>lieation  of  the  aids  of  surgery  to  the 
i-estorative  powers  of  nature.  At  best,  many  sprains 
are  only  imperfectly  recovered  from  because  the  na- 
ture of  the  injury  itself  so  changes  the  delicate  com- 
]>lexily  of  the  joint  that  a  return  to  the  normal  is 
im])ossible.  Fibrinous  adhesions  may  form  because 
of  the  hemorrhage  into  the  synovial  sac.  The  injuries 
to  the  caj^sule,  ligaments,  and  tendons  Ixlonging  to  or 
crossing  the  joint  may  result  in  such  permanent  thick- 
ening as  to  absolutely  eliminate  the  natural  strength 
and  motion  of  the  injured  joint.  Sometimes,  although 
there  is  no  visible  change  in  a  joint  after  apparent  re- 
covery from  a  sprain,  s]>ecial  points  of  tenderness  may 
be  discovered;  the  surface  may  be  abnormally  cold 
and  the  joint  somewhat,  often  quite,  stiff  and  painful 
when  used. 

Tretitmcnt. — This  should  be  directed  towards  reliev- 
ing the  pain,  modifying  the  swelling,  and  hastening 
absorption  of  the  traumatic  exudate  into  and  sur- 
rounding the  joint;  at  the  same  time  placing  lacerated 
and  torn  tissues  into  the  most  favorable  condition  and 
position  for  rapid  repair. 

Moi-e  relief  from  pain  can  be  obtained  by  the  em- 
ployment of  heat  than  cold,  and  the  practice  is  more 
agreeable  to  the  patient.  The  writer  usually  in  all 
cases  of  sprain,  when  seen  within  a  short  time  after 
an  accident,  advises  the  long  continued  and  frequent 
immersion  of  the  injured  joint  in  water  as  hot  as  can 
be  borne.  It  is  still  better  to  add  one  tablespoonful 
of  mustard  powder  to  each  gallon  of  water.  This 
kind  of  heat  relieves  pain,  lessens  hemorrhage  and 
irritative  exudate  within  and  surrounding  the  joint. 
The  i»reliminarv  treatment  may  be  ke])t  up  during  the 
first  eight  to  thirty-six   hours.     In   the   intervals  be- 


SPRAINS  AND  OONTUSIONK  OP  JOINTS,  57 

tween  the  immersions,  the  joint  sliould  he  surrounded 
by  a  ropions  qnnntity  of  notion  wool  held  in  jdace  by 
a  bandage  ajjplied  snfficienlly  tight  to  give  support, 
but  not  to  cause  pain.  Tlie  joint  should  be  elevatcKl 
so  as  to  favor  the  return  circulation  of  the  blood.  Af- 
ter the  end  of  the  first  twenty-four  to  thirty-six  hours, 
all  swelling,  the  result  of  the  injury,  has  taken  place. 
The  object  of  treatment  at  this  time  is  to  hasten  ab- 
sorption of  the  fluids  causing  the  swelling  and  at  the 
same  time  prevent  all  irritation  tending  to  keep  up  a 
pouring  out  of  blood  and  fluid  exudate  from  torn  and 
dilated  vessels.  Gentle  massage  and  frictions  with 
an  avoidance  of  passive  motion  is  valuable,  and  at  this 
time  also  some  pressure  may  be  employed  by  means 
of  a  flannel  bandage  laid  over  a  little  cotton  wool. 
As  the  swelling  begins  to  disappear,  the  massage  may 
be  made  more  vigorous  and  very  gentle  and  moderate 
passive  motion  begun.  Should  this  more  active  treat- 
ment be  followed  by  continued  pain,  it  should  be 
abolished  and  massage  and  the  bandage  relied  upon 
until  most  of  the  swelling  has  disappeared.  At  this 
time,  varying  in  length  from  five  days  to  two  weeks 
after  receipt  of  the  injury,  two  lines  of  practice  may 
be  employed;  the  one  only  applicable  w'hen  there  has 
been  no  extensive  tearing  of  ligaments  and  capsule; 
the  other  being  the  only  rational  practice  if  such  in- 
jury has  taken  place.  If,  upon  moderate  passive  mo- 
tion after  the  swelling  has  gone  down,  there  is  no 
considerable  reaction,  the  indication  is  to  give  support 
and  then  allow  of  a  moderate  and  gradually  increasing 
use  of  the  joint.  Support  can  be  obtained  by  using  a 
flannel  bandage,  or  bettei'  still,  a  more  permanent  and 
reliable  dressing  is  made  from  adhesive  plaster  put  on 
so  as  to  make  even  pressure,  admit  of  limited  motion, 
but  not  to  constrict  and  interfere  with  the  return  cir- 
culation. Adhesive  plaster  dressing  can  also  be  used 
with  decided  advantage  as  a  primary  dressing  in 
sprains  of  moderate  degree  where  there  is  little  ten- 
dency to  swelling.  When  rather  active  or  violent 
reaction  follows  passive  motion,  the  joint  should  be 
immobilized  by  plaster  of  Paris  until  repair  of  torn 


58  MODICKN    TUKAIMKNI-    OF    WOT'NKS. 

tissues  li;is  lalctii  iilatc.  In  ten  days  to  threo  weeks, 
llu^  plaster  of  Paris  can  he  removed  and  inassajjje  with 
passive  motion  renewed  and  a  jiradual  use  of  the 
joint  allowed.  Some  form  of  suj)port  should  be  worn 
for  a  considerable  period  after  bcuinnin^  the  \ise  of 
a  joint  that  has  been  sprained. 

Coiitusio)is  of  joints  follow  falls,  blows,  or  kicks. 
They  may  result  in  a  mere  bruising  of  the  overlying 
joint  structures  or  in  subcutaneous  tearing  of  not  only 
some  of  these  tissue.<j.  but  also  of  the  joint  ca])sule  and 
synovial  sac;  even  bruising  of  the  carlilaji'es  them- 
selves. Hemorrhage  around  or  into  the  joint  accounts 
for  most  of  the  swelling  in  these  cases.  Treatment 
is  by  hot  fomentations,  ]>ressure,  and  massage.  Anti- 
septic incisions  for  the  evacuation  of  effused  blood 
may  be  employed  with  advantage  in  rare  instances  of 
large  extra-articular  blood  accumulations.  Aspira- 
tion may  also  be  of  advantage  in  a  very  small  number 
of  intra-articular  blood  and  synovial  accumulations. 
Both  practices  to  be  of  advantage  should  be  done 
early. 


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COMl'OUND   WOUNDS  OK  JOINTS.  59 

GHAPTEK  XI. 

COMi'OUND  WOUNDS  Ol'  .lOI.NTS. 

Com  pound  wounds  of  joints  are  oil  en  aiiionj^  lb»* 
most  serious  iujurjes  the  surgeon  is  called  upon  to 
treat.  The  seriousness  ol  these  Iraumatisins  de- 
pends upon  two  conditions:  (Ij  Whether  or  not  the 
inflicting  instrument  is  free  from  contamination  by 
inflammation  producing  germs;  (2)  the  size  of  tliii 
joint  injured  and  the  extent  of  the  injury. 

Small  puncturing  instruments,  such  as  shoemakers' 
awls  and  the  like,  when  in  constant  use  are  apt  to  be 
free  from  germs,  and  punctures  into  joints  made  by 
these  instruments  are  not  infrequently  followed  by 
mild  consequences.  Especially  is  this  likely  to  be  so 
if  the  instrument  does  .not  enter  the  skin  directly 
over  the  joint,  but  at  some  distance  away,  or  in  an 
oblique  fashion.  Ice  picks,  axes,  and  other  cutting 
tools  used  in  cutting,  storing,  and  distiibuting  ice 
often  make  wounds  of  joints  which,  although  some- 
times ragged  and  extensive,  are  aseptic.  Most  any 
kind  of  instrument  capable  of  wounding  a  joint  may 
produce  an  aseptic  wound,  but  the  presumption  is 
that  all  wounds  into  joints,  except  those  made  by  a 
careful  surgeon,  are  apt  to  be  followed  by  infection 
of  the  joint.  Wounds  of  small  joints  are  not  of  much 
moment  as  to  danger  to  life,  and  if  the  trauma  is  not 
great,  the  usefulness  of  these  joints  ought  to  be,  in 
part  at  least,  restored. 

Wounds  of  the  joints  of  the  upper  extremity  which 
do  not  seriously  damage  the  component  parts  of  the 
joint  structures  are  not  primarily  threatening  as  to 
life  or  future  usefulness  of  the  joint,  although,  of 
course,  the  functio'n  of  the  joint  may  be  impaired. 
It  is  hardly  conceivable  nowadays  that  as  a  result  of 
such  an  injury  amputation  would  be  called  for:  rare 
exceptions  will  be  met.  But  wounds  into  the  main 
joints  of  the  lower  extremity  are  sometimes  danger- 
ous as  to  life,  and  often  function  is  most  seriously 
impaired,  amputation  being  occasionally  required  to 


60  MODERN    TUEAT.MKNT    OF    WOUNDS. 

save  lilc.  Till'  st'riousiu'ss  ol'  jiuiislioi  woiimls  ami 
coiujiound  ilislucatioiis  and  trafliir(.s  iulo  joiiiis  de 
IK'iuls  iu  jj:;ri'at  nicasuie  upon  the  size  dI  tlie  joinc 
and  I  111*  amount  of  injury,  not  only  of  the  eonii>ouent 
joint  structures,  but  also  the  extension  of  the  injury 
to  the  u})per  and  lower  ends  of  the  bones  goinjj;  ti> 
form  the  joint,  (iri'ater  than  all.  it  must  be  acknowl- 
edged that  the  future  behavior  of  every  compound 
joint  injury  depends  upon  the  degree  of  cleanliness 
employed  at  the  first  dressing. 

Si/iiiitlo)us. — The  escape  of  clear  or  blood-tiuj^cd 
synovial  lluid  is  diagnostic  of  joint  wound,  but  in 
some  cases  of  {(unctured  wounds  no  synovial  tiuid 
escapes,  and  ii  is  practically  impossible  to  say 
whether  or  not  the  joint  has  been  opened.  To  de- 
termine this  question  it  is  best  to  wait  for  a  rapidly 
supervening  secondary  symptom  of  joint  puncture, 
i.  e.,  swelling.  The  degree  of  swelling  will  depend 
upon  the  amount  of  trauma  within  the  joint  and  the 
activity  of  any  germs  introduced.  Slight  or  no  eleva- 
tion of  temperature  will  mark  the  absence  of  infec- 
tion. A  probe  should  not  be  used  for  diagnostic  pui- 
poses,  because,  although  tlie  instrument  be  asei>tic, 
in  its  passage  it  might  force  into  tlie  joint  infectious 
germs  or  germ-beanng  material  which  in  the  passing 
of  the  inflicting  instrument  had  been  left  on  the  way- 
side without  the  joint.  In  open  wounds  inspection 
is  often  all  that  is  necessary  to  determin<'  tliat  a 
jodnt  has  been  injured.  The  eye  should  be  aided  by 
the  aseptic  finger  in  dieftefrmining  the  extent  of  injury 
in  such  cases. 

1)1  infected  compound  joint  injuries  of  oil  Icinds.  wliith 
have  been  infected  and  brought  under  observation 
too  late  for  correct  primary  treatment,  acute  .septic 
inflammation  follow's  in  the  form  of  abscess  within 
and  often  without  the  joint.  The  joint  is  swollen, 
red,  hot,  and  painful.  As  the  flexed  po.sition  allows 
of  easiest  relaxation  and  accommodation  of  effused 
fluids,  nature  brings  it  into  this  position  and  the 
patient  resists  and  complains  of  excruciating  pain  if 
any  attempt  is  made  to  change  the  position.     After 


COMPOUND  WOUNDS  OK  JOINTS.  61 

(lu*  inllainmation  has  Iwslcd  a  ininiltfr  ol  davs,  m- 
l»('i''ba[>s  a  few  weeks,  tlie  pants  of  liie  joint,  oilier  llian 
the  synovial  nKMnbrane  may  be  attacked,  llie  eaili 
lagies  become  eroded  and  the  ligaments  infiltrated 
and  in  part  destroyed.  The  infective  process  may 
extend  above  and  below  the  joint  involvinf^  the  bfmes, 
and  pus  travel  along'  the  lines  of  least  resistance  be- 
tween the  intermuscuhir  pkmes.  There  may  be  great 
swelling  of  the  limb  due  to  this  cellular  inflammation. 
In  moderatel}^  extensive  compound  injurie'S  tliiw  ex- 
tending intlammaition  may  begin  early,  because  th(; 
injury  opens  up  the  avenues  for  infection.  If  the- 
openiings,  however,  happen  to  be  favorably  located 
to  favor  drainage,  the  inflammation  may  remain  local 
until  the  avenues  for  discharge  become  blocked  u[» 
by  accumulating  discharges  and  inflammatory  swell- 
ing. Spasmodic  jerking  of  the  muscles  crossing  the 
joint  is  a  symptom  of  extension  of  inflammation  to 
the  cairtilages.  This  is  more  marl5:ed  during  sleep. 
because  the  patient  is  "off  guard."  This  jerking 
causes  agonizing  pain  and  patients  are  apt  to  aw^aki^ 
with  a  cry  denoting  great  suffering.  The  septic  ab- 
sorption, pain,  and  interruption  of  rest  and  sleep  pro- 
duce great  exhaustion;  the  pulse  becomes  fast  and 
compressible;  the  temperature  ranges  high,  the 
tongue  is  dry.  Now  should  nature  or  art  establish 
good  drainage,  all  bad  symptoms  may  gradually  sub- 
side and  the  patient  recover  wdth  a  more  or  less 
damaged  and  deformed  extremity.  On  the  other 
hand,  pyemia  may  develop,  or  septicemia  and  thL^ 
exhaustive  drain  cause  death. 

The  approach  of  these  dangerous  conditions  is 
marked,  in  pyemia,  by  sweating,  irregular  chills,  and 
elevation  of  temperature.  Such  a  condition  calls  for 
careful  subjective  and  objective  examination  of  all 
parts  of  the  body.  The  w^riter  has  seen  death  from 
pyemia  result  in  less  than  two  weeks  after  a  com- 
pound injury  to  a  joint.  Exhaustive  sweats,  emacia- 
tion, red  cheeks,  d'iarrheia,  continued  fever  of  from  1° 
to  4°  F.  elevation;  increasing  frequency  and  loss  of 
tone  of  the  pulse;  too  rapid  respiration;  restlessness, 
sometimes  drowsiness;  scanty,  high  colored,  usually 


62  MODERN    TREATMENT    OF    WOUNDS. 

alliuiniiKtus,  iiriiu'.  All  iliese  are  the  loreiimiiers  of 
a  fatal  teriiiiuarion.  They  must  be  recognized  early 
for  favorable  ireainieul. 

'Treatment. — Punctured  wouuds  of  joints  should  be 
treated  upon  the  antiseptic  expecUint  plan.  The  skin 
covering  the  joint  should  be  thoroughly  cleansed  with 
soap,  water,  and  a  brush,  washed  in  alcohol  and 
afterwards  in  a  1-lUOO  solution  of  bichloride  of  mer- 
cury in  water.  An  antiseptic  dressing-  is  then  ap- 
plied and  the  joint  placed  at  rest  upon  a  splint. 
Should  the  te^mperature  renuiin  down  and  the  evi- 
dences of  local  iutlammatory  trouble  be  moderate, 
nothing  more  will  be  required.  If,  however,  the  con- 
stitutional and  local  symptoms  indicate  infection,  no 
time  should  be  lost  in  making  a  free  antiseptic  in- 
cision, or  incisions,  into  the  joint.  Copious  irriga- 
tion (bichloride  1-3000)  should  be  employed  in  such  a 
way  as  to  reach  every  recess  of  the  joint.  Drainage 
tubes  should  now  be  inti-oduced  and  the  limb  en- 
veloped in  heav3"  moist  antiseptic  dressings. 

The  joint  should  be  placed  at  rest  upon  splints  and 
elevated,  perhaps  using  the  weight  and  pulley  in 
order  to  prevent  in-itation  of  joint  surfaces  by  mus- 
cular spasm.  The  local  application  of  cold  by  jjack- 
ing  in  ice  is  of  great  value  in  controlling  inllamma- 
tion.  The  cold  does  no  injury  and  undoubtedly 
Inhibits  germ  activity.  To  be  of  service  it  should  be 
applied  around  the  antiseptically  dressed  joint  in 
much  the  same  way  as  ice  is  packed  around  the  can 
of  an  ice-cream  freezer.  The  Leiter  coil  and  similar 
appliances  are  tinkering  tools  in  such  cases.  Con- 
tinuous antiseptic  irrigation  with  ice  cold  fluid  is 
often  of  great  value.  In  extensive  injury  use  the 
same  plan  of  treatment,  that  is,  painstaking  anti- 
sepsis, irrigation  and  drainage,  antiseptic  dressings. 

Amputation  should  never  be  thoiight  of  in  civil  prac- 
tice unless  the  vessels,  nerves,  and  tendons  crossing 
the  joint  are  so  damaged  that  repair  with  usefulness 
is  out  of  the  question.  Atypical  or  even  tyi)ical  resec- 
tions may  be  done.  It  used  to  be  thought  that  pri- 
mary amputation  was  recjuired  in  gunshot  and  other 


(;(>MPOrjNI>    WOUNDH  Olt'  .lOINTH.  (»:> 

liiceriitiiij;'  and  (leHtructivo  joint  injurif-H.  Since  ex- 
pCM'tanl:  anliHcplict  di-ainagc;  vvilii  immobili/ation, 
pracl'iwd  HtkI  by  \/,\\\<^t'\y\)ci:k  and  oIIum*  (J(;rnian  Bur- 
geons diJi'ing  the  wai-  witli  France  liav(;  j^iven  rn<»t 
satisfactory  results,  Die  SMrj,^eon  of  to-day  wonld 
hardly  be  justified  in  amputating  as  a  j)iMniary  jn-o- 
cedure.  Tf  in  infcoled  joiiils  tlie  line  of  ireatracnt  iu- 
di(%aited  does  not  succe(;d, — and  it  may  succeed  even 
after  wide  suppuration,  if  only  the  drainage  through 
all  infeoted  tissues  be  made  ample  and  maintained  un- 
til repair  is  well  oistablished, — then  amputation  ought 
to  be  consiidered  and  not  too  long  delayed.  l*yemia 
may  be  C'heicked  by  extensive  incisions  into  and  above 
and  below  the  primary  foicns.  Secondary  collections 
must  be  opened  and  drained  early.  Amputation  may 
be  done,  but  if  at  all,  it  must  be  do'ne  after  saoondary 
foci  have  been  detected  and  drained,  and  the  incisions 
into  and  around  the  joints  have  proven  insufficient  to 
check  infection.  When  hectic  fever  threatens  de- 
struction by  exhaustion,  amputation  is  imperative. 

How  to  Amputate. — ^The  patient  should  be  freely 
stimulated  by  strychnia  and  alcohol  and  a  rapid 
operation  performed  under  as  short  and  not  too  pro- 
found anesthesia  as  possible.  The  main  vessels 
should  be  tied  and  oozing  prevented  by  proper 
sponge  packing  and  bandaging.  Few  or  no  stitches 
ought  to  be  introduced.  If  the  shock  of  the  operation 
is  sustained,  recovery  is  usually  assured.  The  writer 
has  been  surprised  how  wonderfully  recovery  has  fol- 
low^ed  among  the  apparently  hopeless  cases  of  sep- 
ticemia of  the  kind  under  consideration  which  at  his 
hands  have  been  treated  by  amputation. 

Heart  stimulants,  alcohol,  and  easily  assimilated. 
perhaps  predigested  food,  should  be  given;  sponging 
of  the  surface,  copious  draughts  of  water,  all  aid  in 
carrying  the  treatment  of  these  cases  to  a  successful 
termination.  The  employment  of  antistreptococcas 
serum  would  be  useless  in  chronic  cases,  but  might 
possibly  be  an  advantage  in  the  early  periods  of  acute 
iufectiou;  but  here,  as  elsewhere,  treatment  should  be 
directed  towards  prevention  and  limitation  by  r/mov  d 
of  the  cause  of  infection. 


64  MODERN    TltKATMENT    OI'    WitlNDS. 


CHAITKK  Xll. 
JlEAl)  I.X.UKIKS. 

aS((///>  Wvuiiih. — A  (011111100  impi'essiuii  pri'vaiU  ihat 
scalp  wounds  dilTei*  iiiiK-h  in  their  beliavior  from 
wounds  in  otlun-  localities,  and  therefore  special  rules 
of  treatment  are  necessary.  This  is  not  so;  all  that 
is  essential  is  a  recognition  of  the  anatomical  i»ecul- 
iarties  of  the  part  and  the  care  demanded  to  render 
the  wound  area  free  from  }i;erm-carrying  materials. 
JSome  scalps  are  loaded  with  oil,  dirt,  and  ei)iiliclium, 
and,  when  wounded,  require  more  than  ordinary  ef- 
forts to  disinfect;  however,  a  vigorous  use  of  soap 
and  water,  alcoliol,  and  bichloride  solutions,  cinphii/ed 
m  the  order  named,  will  disinfect  efficiently.  It  is  usu- 
all}'  AYise  to  cut  away  the  hair  in  the  immediate  vi- 
cinity of  a  scalp  wound,  and  in  all  complicated  cases, 
a  large  area,  perhaj>s  the  whole  scalp,  sliould  be 
shaved  and  then  thoroughly  disinfected. 

Incised  Wounds. — Hemorrhage  should  be  treated  as 
elsewhere,  only  it  must  be  recalled  that  the  rather 
broad  and  firm  surfaces  cannot  bleed  much  if  approxi- 
mated by  suture;  hence  few  ligatures  are  required. 
After  preparation,  incised  scalp  wounds  should  be 
treated  as  skin  wounds  in  other  parts.  Silkworm  gut 
is  the  best  suturing  material,  and  the  stitches  should 
be  introduced  sufficiently  close  together  to  bring 
about  accurate  approximation,  but  not  so  close  as  in 
deep  skin  wounds  in  most  other  parts,  where  it  may 
not  infrefjuently  be  good  practice  to  use  supei-ficial 
as  well  as  through  and  through  stitches. 

The  simplest  wounds  may  be  dusted  with  some  pro- 
tective drying  powder  without  an  overlying  dressing, 
but  as  a  rule  the  same  practice  as  to  the  dressing  of 
wounds  in  general  should  apply  to  scalji  wounds. 
Stitches  can  be  removed  in  from  four  to  six  days. 

Scalp  wounds  resulting  from  falls,  blows  with  clubs, 
canes,  beer  bottles,  and  the  like,  often  resemble  very 
nnicli  tlie  ordinarv  incis(Hl  wounds,  onlv  Ihat  thev  are 


HI'JAIJ    INJIJIIIKS.  Oij 

apt  to  bo  ii'i-ogular  and  tlu;  edgen  i>i-0Heiit  u  Hlightly-cou- 
liiHcd  iii)j)earane('  willi  a  tendency  to  (iV(;rHion.  Kiich 
vvoniids  i(Miuire  the  same  kind  of  treatment  an  inciHcd 
wounds  proper.  '^IMiey  may  be  very  exlensive,  eH])o- 
eially  wlien  du(;  (o  tlie  liead,  or  in  women  I  lie  long  luiii-, 
being  caught  between  or  in  moving  machinery.  Large 
parts  of  the  scalp  have  been  lorn  off  the  skull  or  flaps 
of  consideral)le  size  lifl(Ml  u[).  In  the  former  case,  an 
attempt  should  be  made  to  suture  the  detached  scalj) 
in  place  with  the  hoi>e  that  union  will  occur;  this  fail- 
ing in  whole  or  in  })art,  repair  of  the  raw  surface  may 
be  aided,  after  granulation  has  been  established,  by 
skin  grafting.  Flaps  should  be  sutured  carefully,  and 
almost  invariably  it  will  be  found  that  they  will  unite 
because  of  the  abundant  blood  supply. 

When  a  scalp  wound  is  complicated  by  a  deeper  in- 
jury through  the  aponeurosis  of  the  occipito-frontalis 
muscle,  opening  up  channels  for  infection  between  the 
muscle  and  the  pericranium,  it  is  unwise  to  use  stitches 
at  all  if  the  wound  is  a  small  one,  and  if  a  long  one, 
only  a  comparatively  few  stitches  ought  to  be  intro- 
duced, the  reason  being  that  if  our  efforts  at  disinfec- 
tion have  not  been  successful  avenues  of  escape  for 
the  products  of  infection  must  be  free,  because  septic 
inflammation  of  a  most  dangerous  form  may  occur  in 
the  cellular  tissues  overlying  the  pericranium,  and 
this  infection  invade  the  skull  through  the  iiumerous 
veins  connecting  with  the  meninges,  causing  either 
an  intracranial  abscess  or  a  suppurative  lepto-menin- 
gitis;  therefore,  such  wounds  should  not  be  tightly 
closed  by  suture,  but  they  should  inmriaUy  he  drained. 
In  case  infection  of  the  kind  under  consideration  has 
taken  place,  the  original  wound  must  be  reopened  im- 
mediately; perhaps  other  openings  may  be  required 
to  establish  free  drainage.  If  a  decided  betterment, 
both  in  the  local  and  constitutional  condition  (not  in- 
frequency  of  an  alarming  type),  does  not  follow  within 
a  few  hours  at  longest,  the  skull  should  be  carefully 
inspected  under  and  in  the  area  nearest  about  the 
original  injury,  and  it  may  be  that  pus  will  be  detected 
coming  out  of  one  or  more  of  the  numerous  openings 


GG  MODERN    TliKATMENT    UF    WolNHS. 

loiincfliiig  the  exu-riur  with  ihe  interior.  Such  a 
coudition  would  probably  deiiiaud  the  use  of  the  chisel 
or  trephiue  in  order  to  iimii  or  prevent  by  disinfection 
and  drainage  a  fatal  intracranial  alfection.  Of  course, 
if  there  are  symptoms  of  mischief  wilhin  the  skull  de- 
terminable by  known  means  of  cerebral  localization, 
the  chisel  or  trephine  should  be  used  over  the  recog- 
nized area,  not  forgetting,  however,  that  that  part  of 
the  skull  immediately  under  the  seat  of  primary  in- 
jury, and  where  the  greatest  intensity  of  intlammation 
began,  is  the  most  likely  portion  for  attack  by  the 
surgeon,  who  should  not  be  lured  away  by  symptoms 
seemingly  pointing  in  other  directions,  unless  they  are 
of  a  positive  kind.  In  acute  intracranial  inflamma- 
tory conditions  many  of  our  usually  reliable  localiz- 
ing symptoms  are  untrustworthy. 

Contusions  of  the  scalp  are  common  and  result  from 
the  same  class  of  injuries  as  scalp  wounds  following 
blows,  falls,  etc.  In  the  majority  of  cases  the  swell- 
ing resulting  from  blood  extravasation  and  exudation 
is  limited  and  of  little  importance;  all  that  is  neces- 
sary in  the  way  of  treatment  being  the  application  of 
very  hot  fomentations.  Cold  is  a  favorite  remedy 
with  many  surgeons,  but  the  writer's  preference  Is 
for  moist  heat.  If,  as  not  infrequently  happens,  the 
patient  complains  of  pain  and  a  ''hot,  burning  fever" 
in  the  head,  the  application  of  cloths  wrung  out  of  ice 
water  or  the  use  of  the  ice  cap  is  most  grateful. 

Sometimes  quite  extensive  hemorrhage  occurs  un- 
der the  scalp,  causing  large  fluctuating  swellings, 
which,  fortunately,  gradually  disappear  under  the 
form  of  treatm-ent  just  recommended.  It  is  a  good 
rule  never  to  incise  these  swellings  unless  there  are 
both  local  and  constitutional  signs  of  infection  in  the 
swelling,  then  free  incision,  antiseptic  iirigation.  and 
the  establishment  of  drainage  are  demanded.  Occa- 
sionally a  form  of  swelling  following  contusions  of  the 
scalp  is  met  with  which  presents  ])uzzling  features  to 
the  young  surgeon,  and  not  invariably  is  the  elder  cer- 
tain as  to  its  meaning  when  perchance  the  sufferer 
may  have  I'eceived  such  a  blow  ns  to  shake  up  his  cere- 


IIICAI)    INJUIIIIOH.  07 

bral  balancing  powei-H  Lo  a  dcgifM;  I  liat  i-aLlic'r  i]id(;iL- 
nite  ''brain  HyinpLom.s"  inon;  Lhun  suggcHt  Uie  poHHi- 
bility  ol  .skull  Iraciure  with  coniprcs.sion  of  tbo  biain. 
This  lonn  of  .swelling  is  cau.sed  by  liemori'iiago  undci' 
the  pericranium.  It  i.s  a  circumscribed  Hwelling  and 
is  limiled  between  the  sutures  of  the  bonces  which  it 
covers.  liccause  of  its  exx>osed  jiosition,  tlie  parietal 
eminence  is  a  favored  seat  for  this  swelling,  which 
at  first  is  soft  in  character,  but  soon  assumes  hard 
elevated  borders,  the  central  portions  remaining  soft. 
It  is  this  ridge-like  border  vv'hich  causes  misgivings. 
To  the  fingers  examining  this  edge  and  the  soft  center, 
the  sensation  of  fracture  of  the  skull  with  depression 
may  be  experienced.  But  when  it  is  remembered 
that  the  edge  of  the  swelling  is  raised  above  the  bone 
outside  the  area  of  injury,  and  also  that  by  firm  press- 
ure with  the  finger  or  some  non-cutting  instrument 
the  border  can  be  indented,  of  course  the  idea  that 
fractured  bone  is  being  felt  must  be  abandoned.  The 
indurated  border  is  due  to  a  fibrinous  exudation. 

Swellings  under  the  scalp  are  found  in  new  born 
babes  and  result  from  diflScult  labor  with  or  ^vithout 
instrumental  interference.  Mild  forms  of  this  swell- 
ing are  extremely  common  and  excite  no  comment, 
but  the  severer  forms,  especially  the  sub-pericranial 
variety,  invariably  cause  great  anxiety  and  apprehen- 
sion upon  the  part  of  parents  and  family.  The  busy 
and  inquisitive  neighbor  may  stir  up  considerable  of 
a  rumpus  if  the  attending  physician  does  not  quiet 
matters  by  an  explanation  and  favorable  prognosis. 
He  should  not  fail  to  mention  incidentally  to  some 
relative  that  in  rare  instances  the  brain  is  injured  by 
the  compressing  force  of  the  difficult  labor,  but  as  far 
as  the  external  swelling  is  concerned,  it  is  of  little  mo- 
ment, and  will  disappear  in  a  few  days  or  a  week  or 
so.     The  treatment  is  as  for  ordinary  contusions. 

TREATMENT  OF  COMPOUND  FRACTURES  OF  THE  SKULL. 

Every  compound  fracture  of  the  skull  vault,  with  or 
without  depression,  in  which  there  are  brain  symp- 
toms other  than  those  of  a  most  transient  character 
due  to  contusion  (concussion")  of  the  brain,  should  be 


68  MODERN    TRKATMENT    OF    WOUNDS. 

submitted  to  operative  interference.  Where  there 
are  symptoms  of  (•omi)ression  of  tlic  Inain  with  slij^ht 
or  tio  evidences  of  depression  of  bone,  the  skull  shtmld 
be  trephined,  and  almost  invariably  one  of  two  con- 
ditions will  be  met  with,  either  a  cloi  will  ix'  found 
betwi'eii  the  dura  and  the  skull  (sometimes  or  more 
rarely  beneath  the  dura),  or  a  fragment  of  the  internal 
table  will  be  recoji!;nized  which  is  either  depressed  so 
as  to  push  the  dura  down  or.  liavinj;  toiii  lliron<jjh  the 
dura,  penetrates  the  brain. 

Every  depressed  fracture  of  the  skull,  simple  or 
compound,  with  or  without  brain  symptoms,  should 
be  trephined  and  the  dei)ressed  bone  elevated.  In 
every  case  where  clots  are  found  they  should  be  re- 
moved, and,  unless  an  accurate  hemostasis  is  obtained, 
drainage  should  be  established.  In  every  case  of  tre- 
phining, no  matter  for  what  ])urpose,  if  there  is  the 
slightest  suspicion  that  absolute  asepsis  may  not  fol- 
low in  the  primary  rei)air  of  the  deeper  parts  of  the 
uouiKh  drainage  should  be  provided  for,  the  drain 
passing  to  the  deepest  part  of  the  wound.  A  depend- 
ent skull  o])ening  may  be  essential  for  the  establish- 
ment of  good  drainage. 

The  first  essential  procedure  in  the  management  of 
a  compound  or  depressed  fracture  of  the  skull  is  the 
shaving  of  the  entire  scalp  and  its  sterilization  by  the 
most  painstaking  use  of  antiseptics.  The  wound  it- 
self should  be  washed  with  antiseptics,  but  just  be- 
fore the  beginning  of  the  operation  the  wound  and 
scalp  in  its  immediate  neighborhood  sliould  be  irri- 
gated and  sponged  with  normal  salt  solution,  as  it  is 
desirable  that  no  irritant  of  a  chemical  kind  should 
come  in  contact  with  the  brain  or  its  membranes  dur- 
ing the  operative  procedure.  Chloroform  should  be 
the  anesthetic  of  choice.  Sterile  towels  must  be  ar- 
ranged so  as  to  protect  the  wound,  special  pains  being 
employed  in  the  arrangement  of  the  towels  so  that 
the  ojterator  and  assistant  will  not  by  chance  touch 
the  patient's  face,  the  chloroform  mask,  or  the  anes- 
thetizer's  hands.  If  the  patient  is  brought  to  the  sur- 
geon aftei-  infection  of  the  scalp  wound  has  occurred. 


I'l.ATi:  \'. 


Tlic  l',>iii;ii<-li  louniicnict  ;i|i|ilicil.  l'ii>iliiiii  uf  i  In-  aiirstlii/cr,  ttc,  in  an  (i]p<Ta- 
lion  for  comiioiind  tVactuic  ul'  tlic  skull.  (  Vvnn  a  iiaticnt  in  tjic  Clarksuu 
Jlosiiital.) 


IIIOAD   INJUUIEH.  69 

ii()(  only  llic  (mI^cs  of  llu'  v\\\  or  torn  S(;il|»  nnisl  he 
Htcrilized,  bu(  ihe  wliohi  wound  area,  including  iIh; 
bone  surface.  'To  do  (IiIh  it  in  bcHi  to  (d(!vat(^  I  lio 
wound  (lai)H  and  aflcr  irri^alion  and  I  lie  removal  of 
all  foreign  inatorialH,  lo  pour  earbolic,  acid,  OH  per 
cent.,  into  the  wound,  swabbing  this  about  in  every 
i-ecess  by  means  of  a  piece  of  slei-ile  gau/e  held  in  a 
suitable  forceps,  washing  the  acid  out  within  a  min- 
ute or  two  with  alcohol.  Th(!  wound  is  then  irrigated 
with  a  corrosive  sublimate  solution,  followed  by  a 
normal  salt  solution;  it  is  now  in  a  condition  for  the 
operator  to  attack  the  deei)er  parts  without  the  fear 
of  carrying  the  infection  from  the  more  superiicial 
structures. 

There  is  absolutely  no  danger  in  using  carbolic  acid 
in  this  way,  its  entrance  between  all  fissures  to  the 
bottom  of  the  infection  is  a  safeguard.  'Numerous 
practical  experiences  haA^e  proven  the  safety  and  ad- 
vantages of  the  use  of  the  antiseptics  advocated. 
There  may  be  others  as  useful,  but  with  them  the 
writer  has  never  been  able  to  handle  his  own  cases  so 
successfully,  and  he  feels  quite  capable  of  forming  an 
opinion  if  a  wide  experience  and  extended  opportuni- 
ties for  becoming  practically  acquainted  with  the 
work  of  others  means  anything. 

In  order  to  keep  the  field  of  operation  free  from 
flooding  of  blood  from  any  incisions  made  through  the 
scalp,  either  chain  ligatures  may  be  used,  or,  better 
and  simpler,  an  Esmarch  tourniquet  can  be  applied 
around  the  'head,  crossing  over  the  eyebrows  and  un- 
der the  occipital  protuberance.  This  bandage  should 
not  be  removed  until  after  the  operation  has  been 
finished,  and  the  superficial  dressings  applied  and 
held  against  the  wound  by  an  assistant's  hand.  The 
work  is  completed  by  the  application  of  a  sufiicient 
antiseptic  dressing  held  in  place  by  a  smoothly  ad- 
justed recurrent  bandage. 


70  MOPKKN  tiu:atmi:nt  of  wounds. 


CHAPTER  XIII. 
P01SONEJ3  AM>  J)lSSi:CTION   WUL  NDS. 

Poisoned  wounds  may  'be  deliued  as  a  class  a!  iufec- 
lious  it'SiiUiug  from  microbic,  chemic,  oi*  mixed  bio- 
cliemical  iul'ecliou,  having  ceriaiu  special  well  reccg- 
iiized  characteiislics  wliicli  vary  iu  many  respects, 
boCh  etiologically  and  iu  their  clinical  course,  from 
wounds  as  met  with  in  every-day  accidental  and  op- 
era lIvc  surgery. 

Poat-Mord'ni  or  Diancction  Wound!^. — An  iucieased 
knowledge  oi  the  pathology  of  diseases  and  a  better 
appreciation  of  the  means  at  our  command  to  prevent 
or  control  infections  has  diminished  the  freiiueucy 
with  which  post-mortem  or  dissection  wounds  are 
met  with,  which  give  rise  to  symptoms  of  importance. 
A  poisonous  substance  developed  in  a  dead  body  may 
enter  through  .a  pritk,  cut,  or  abrasion,  and  cause 
either  a  local  inflammation  or  a  rapid,  more  or  less 
general  blood  poisoning.  The'poison,  if  derived  from 
bodies  of  indiWduals  recently  dead,  is  more  virulent 
than  from  those  in  the  more  advanced  stages  of  de- 
composition, and  in  general  it  may  be  stated  that  the" 
more  decomposed  the  body,  the  less  the  danger.  It 
must  be  remembered,  however,  that  Pasteur  proved 
that  certain  diseases  of  animals  (found  in  man  also) 
could  be  contracted  by  healthy  animals  grazing  over 
ground  in  which  was  buried  the  bodies  of  animals 
long  since  de'ad  from  these  same  diseases.  Certain 
specific  diseases  can  be  inoculated  from  the  bodies  of 
individuals  dead  with  these  diseases. 

Bodies  dead  from  diseases  such  as  erysipelas,  septic 
peritonitis,  land  more  especially  the  puerperal  type 
are  responsible  for  many  of  the  most  serious  cases 
of  post-mortem  wounds  met  with;  and  inoculation 
from  the  living  through  the  injured  skin  of  the  sur- 
geon wliile  engaged  in  examining  or  operating  upon 
patients  suffering  from  these  infective  diseases  may 
cause  the  most  serious  mischief. 


POISONED   AND    DISHKOTION    WOUNDS.  71 

It  is  .said  that  inoculation  may  take  place  tlirough 
the  .unbroken  skin,  entering?  through  tlie  hair  follicles, 
etc.,  but  this  ir-  llieory.  No  man  who  is  actively  en- 
gaged in  using  his  hands  in  medical  and  surgical  work 
can  be  sure  that  (here  may  not  be  one  or  more  abra- 
sions or  other  minute  passageways  for  microbic  or 
bio^'hemfical  poisoniiiig.  Ordinary  ocular  inspeetion 
may  not  disclose  these  channels,  but  they  are  pi-esent 
just  the  same  from  lime  to  time. 

Sfir  James  Paget  (Clinical  Lectures  and  Essays) 
says:  "For  not  all  men  ,can  be  made  ill  by  a  virus  from 
a  dead  body,  nor  can  the  same  man  be  made  ill  at  all 
times;  but  there  must  be  what  is  called  a  fitting  soil 
for  the  virus  to  work  in.  We  know  no  more  what  this 
soil  is  than  we  do  what  the  virus  is;  Tve  have  to  use 
figurative  expressions;  but  we  need  not  doubt  that 
they  imply  facts,  and  that  for  any  lining  body  to  be 
made  diseased  by  a  dead  one,  there  musit  be  certain 
living  materials  which  can  be  diverted  by  the  dead 
ones  from  their  normal  relations  and  turned  into  a 
morbid  course." 

Two  facts  have  'been  well  recognized:  First,  a  per- 
son whose  duty  calls  him  to  make  frequent  post-mor- 
tem exaiminations  can  become  almost  immune  against 
post-mortem  poisoning;  his  system  becomes  protected 
against  the  virulence  of  poisons;  second,  a  debilitated 
state  of  the  general  health  predisposes  to  infection. 
The  wr*iter  has  seen  many  cases  of  infection  of  the 
hands  among  butchers,  cooks,  and  dish-washers,  but 
these  infections  were  almost  without  exception  local 
in  character  and  no  death  or  dangerous  constitutional 
conditions  are  recalled.  Some  of  these  people  were 
quite  ill  and  a  few  suffered  serious  local  infections, 
but  as  the  animal  material  handled  by  these  people 
was  from  healthy  sources,  virulent  poisoning  was  not 
to  be  expected. 

Types  of  Post-Mortem  Poisoning. — Local. — As  a  re- 
sult of  constant  local  irritation  of  the  hands  by  the 
juices  of  dead  bodies  a  form  of  wait  is  met  with  which 
is  somewhat  analogous  to  the  venereal  warts  caused 
by  gonorrihea  and  is  described  by  Stanley  Boyd  as 

6 


iL'  MoltlOHN    TREATMENT    OK    WolNDS. 

llie  ••Di.sftit'Liiiig  poller's  wari.""  il  results  fioiu  ii'ri- 
latiou  and  not  infeciiuu,  aud  is  I'ouud  iipou  ilic  dorsal 
surfaces  of  the  hands  and  fingers.  Tiiere  is  no  ulcera- 
tion, but  there  may  be  cracks  and  fissures.  The  multi- 
plicily  of  the  wai-is  distiu'j^iiis'h'.'^  them  Ironi  epi- 
thelioma. 

An  annoying,  but  not  dangerous,  form  of  local  in- 
fection is  often  found  upon  the  hands  of  students 
engaged  in  dissection  and  sometimes  also  upon  the 
hands  of  physicians  who  not  infrcijuently  make  post- 
mortem examinalions.  It  consists  in  one  or  several 
jtustules  whicL  develop  u])on  the  dorsum  of  the  fingers 
and  seem  to  select  by  preference  the  knuckle  areas. 
These  pustules  are  sometimes  found  upon  the  dorsum 
O'f  the  hands,  wrist,  and  lower  fore-arm,  and  when 
found  in  these  latter  localities,  usually  take  on  the 
characteristics  of  small  boils  w'ith  perhaps  rathi*r 
extensive  inttaiued  circumferences.  Whether  pustu- 
lar or  furuncular  in  kind,  they  tend  to  be  quite 
chronic,  and  unless  treated  after  an  especial  fashion, 
ulcerating  surfaces  form  beneath  the  scabs  of  their 
dried  secretions.  Intiammations  of  a  very  chronic 
kind  are  also  found  around  about  and  under  the  nails, 
the  result  of  local  post-mortem  infection. 

Treatment  of  Local  Infection. — "NVarts  are  success- 
fully treated  by  the  use  of  caustics,  and  for  those  who 
must  continue  to  expose  the  hands  to  irritation  this 
is  the  best  treatment.  The  caustic  must  not  be  too 
powerful  and  perhaps  glacial  acetic  acid  applied  every 
day  or  every  second  day  is  the  best.  It  is  said  that 
Ihe  constant  use  of  extract  of  belladonna  is  curative. 
When  radical  means  are  desired,  tlie  warts  should  be 
removed  with  the  scissors,  the  bases  curetted,  and 
to  the  raw  surfaces  pure  carbolic  acid  applied.  If 
the  warts  are  numerous,  the  action  of  the  carbolic 
acid  may  be  limitcxl  and  pain  much  modified  by  mop- 
ping the  cauterized  surfaces  with  alcohol.  A  wet 
antiseptic  dressing  sliould  be  used  and  the  probabili- 
ties are  that  repair  will  soon  take  place.  A  boracic 
acid  ointment  dressing  may  be  used  with  advantage  as 
repair  progresses.    In  some  obstinate  cases  it  is  neces- 


J'()IS<JN101>   AND   JJISHKCTJON    WOUNDH.  73 

navy  Lo  repcuL  Llie  carbolic  acid  and  alcoJiol  applica- 
Lioua.  Wiiero  tis«ui-e,s  aud  cracks  coiiipJicaLe  Lliewe 
cawea,  the  carbolic  acid  should  be  made  Lo  reach  the 
bottoms  of  these  separations.  The  pustules  may  be 
treated  by  ojiening  them  thoroug'hly,  applying  car- 
bolic acid,  aud  theu  a  wet  a uti. styptic  dressing,  or  the 
pustules  may  be  curetted  out  and  then  apply  the  acid 
anid  dressing;  buL  it  must  be  remembered  that  success 
in  treatment  depends  ui>on  the  prevention  of  the  ac- 
cuinmration  of  the  irdtatiug  pus  beneath  scabs  or 
dried  dressings.  Local  inllaimmatory  conditions  in- 
volving the  nails  are  types  of  purulent  onychia.  Sup- 
puration takes  place  around  about  and  also  beneath 
the  nail.  The  matrix  will  be  affected  in  whole  or  in 
part  and  as  la  oonsequence  a  part  or  all  of  the  nail  is 
loosened  from  its  bed.  The  matrix  is  converted  into 
granuiatioin  tissue.  The  condition  is  a  painful  one 
and  apt  to  be  slow  in  its  repair. 

In  the  early  stages,  the  tissues  around  the  nail,  usu- 
ally on  one  side,  ought  to  be  incised  and  pure  carbolic 
acid  or  nitrate  of  silver  stick  applied  to  the  cut  sur- 
face. Ais  soon  as  it  is  clear  that  suppuration  has  or 
is  about  to  occur  under  the  nail  a  piece  of  the  nail 
should  be  cut  away  and  the  infecte'd  surface  beneath 
touched  with  cartbo'lic  acid.  Wet  antiseptic  dressings 
ought  to  be  used.  Hot  foimentations  are  grateful.  In 
spite  of  prejudice  b}^  the  profession,  the  patient  will 
appreciate  and  be  grateful  for  a  hot,  thick  flax-seed 
meal  poultice,  mixed  up  by  using  a  moderately  strong 
solution  of  carbolic  acid  or  bichloride  of  mercury. 

The  constitutional  effects  of  post-moytem  wounds 
are  produced  by  the  entrance  of  poisons,  microbic, 
chemical,  or  both,  into  the  circulation,  usually 
through  the  lymiphatic  system.  The  severity  of  the 
symptoms  depends  upon  the  amount  and  character  of 
the  poison  absorbed,  as  well  as  the  individual  sus- 
ceptibility. 

A  septic  hjmphangitis  makes  itself  evident  usually 
wdthin  twentj-four  hours  after  inoculation. — there  is 
pain  and  throbbing  of  the  fingers  and  possibly  arm. 
In  a  few  hours  red  streaks  mav  be  observed  running 


74  MODERN    TUKAT-MKNT    OF    WOUNDS. 

towiirds  I  he  iK-ari-st  ^laiuLs.  II'  the  infectiou  is  lini- 
ited  to  the  maiu  Ijinphatics,  these  red  streaks  are  iso- 
lated, otherwise  all  the  lymphatics  become  iuvolved 
and  a  more  or  less  dilTuse  cellulitis  develops  and 
softened  aieas  can  be  felt.  In  the  isolated  type  of 
lvnil>han<iitis  the  sjtread  of  the  poist)n  seems  to  be  in 
a  measure  arrested  by  the  glands  along  the  course  of 
the  lymphatics.  These  glands,  in  order  from  below 
uj),  become  swollen  and  painful  and  may  suppurate. 
DilVuse  sni>i)ura1  ion  of  tlu^  axilla  and  even  jtectoral 
region  may  occur. 

Constitutional  symptoms  may  be  profound;  high 
tempei-atiire,  delirium,  and  marked  depression  is  ob- 
5:erved.  Death  oecasioually  follows  this  jxoisoning 
in  from  two  to  four  days.  Every  post-mortem 
wound  should  be  encouraged  to  bleed,  and  if  there 
are  no  cracks  upon  tlie  lips,  it  oug'ht  to  be  sucked. 
This  will  remove  some,  if  not  all.  of  the  poison.  Tlie 
wound  should  then  be  cauterized  with  glacial  acetic 
acid  or  carbolic  acid,  both  of  which  drugs  should  al- 
ways be  at  hand  when  post-nini'fem  woik  is  being 
conducted. 

Simple  isolated  lymphangitis  requires  little  treat- 
ment except  the  antiseptic  treatment  of  the  point  of 
inoculation.  Hot  fomentations,  ;painting  along  the 
lymphatics  with  tr.  iodine,  or  extract  of  belladonna 
and  glycerine  may  possibly  do  some  good. 

Suppurating  glands  should  be  incised  and  all  forms 
of  cellulitis  treated  upon  the  prineii)]es  already  laid 
down.  Drainage  and  supporting  cons'titutlonal  treat- 
ment are  the  keys  to  success. 

Iiiscff  fiiinf/s  and  hifra  usually  require  no  special 
treatment  further  than  the  local  application  of  dilute 
ammonia  water  or  spirits  of  camphor.  Tf  many  bites 
have  been  received  at  the  sam(^  time  and  these  are 
clustered,  there  may  be  considcM-able  swelling.  Con- 
stitutional symptoms  resulting  from  the  absorption 
of  the  acid  poison  of  stings  and  bites  are  in  rare  in- 
stcinces  chai-acterized  by  a  general  dejiression  suffi- 
cient to  demand  energetic  treatment.  Actively  dif- 
fusible heart  stimulants  must  be  given  internally  and 


J'OISONIOI)    AN1>    IMHSK^TJON   WOLNOH.  to 

by  liy])<)(l('iniic  nuMjiciil  ion.  W'Jicii  ;iii  iiiHecl  hMii^  or 
bite  is  followed  by  Hevcrct  local  iiillaiiiiiiatoi-y  nigriH, 
togetiiei'  with  coiiKtitutioiial  syinptomH  indicative  of 
sepsis,  it  is  j)r('suiiiab]e  that  a  mixed  infection  has 
occuirred,  viz.,  a  cliciiiical  jioisoiiinj^'  from  tlie  sting  or 
bite  combined  with  a  mici-obic  infeclion.  If  the  sting 
has  been  brolien  oft'  and  left  in  the  skin,  it  should  be  re- 
moved. Jn  any  case  simulating  a  poisoned  wound,  as 
seen  in  septic  or  ordinary  bio<;li<'ini(al  infection,  in- 
cisions should  be  made  to  permit  of  free  drainage  and 
escape  of  the  poisonous  products.  Especially  should 
this  be  the  rule  when  the  sting  or  bite  has  been  made 
in  tissues  where  loose  cellular  elements  abound,  as 
the  orbit,  around  the  anus,  and  external  genitals. 

Bites  from  the  spider  species  are  oftentimes  of  seri- 
ous consequence  and  require  the  same  treatment  indi- 
cated above. 

Serpent  Bites. — Rattlesnake,  moccasin,  copperhead, 
and  viper  bites  are  often  follow'ed  by  grave  symptoms, 
and  sometimes  by  death.  In  India  snake-bites  cause 
thousands  of  deaths  every  year.  The  rattlesnake  is 
responsible  for  most  of  the  deaths  from  serpent  bites 
in  the  United  States.  Poisonous  serpent  venom 
seems  to  be  composed  of  two  elements,  one  a  direct 
depressant  or  paralyzer  of  the  cardiac  and  respiratory 
centers,  the  other  a  disorgauizer  of  the  blood.  The 
blood  becomes  thin,  loses  its  power  of  coagulation, 
and  exudes  from  small  blood-vessels.  Wide  extrava- 
sation may  occur.    The  red  corpuscles  disintegrate. 

The  first  effect  of  the  poisonous  bite  is  pain,  rapid 
swelling,  and  a  black-green  or  purple  discoloration  of 
the  skin  in  the  immediate  neighborhood  of  the  bite. 
These  local  symptoms  develop  within  an  hour,  even 
within  a  few^  minutes.  As  the  local  symptoms  make 
their  appearance,  sometimes  before,  constitutional 
signs  are  manifested.  Nausea  and  vomiting  are  apt 
to  be  early  symptoms  and  may  follow  as  rapidly  after 
the  bite  as  vomiting  from  a  hypodermic  emetic  dose  of 
apomorphia.  The  heart-beat  becomes  rapid  and  fee- 
ble, the  respiration  labored,  and  the  skin  clammy. 
Should  the  poisoning  end  in  early  death,  according  to 


70  MuDElJN    TUEATMENT    OF    WtHNKS. 

\\\'h-  Miiclifll  iCaruialti,  "local  i'Xlra\asalion  luav  br 
all  I  hat  is  visibk',  but  il"  it  be  [(oslpomHl  tor  a  slioi-i 
lime,  ilieii  siiialhM-  ('xti-avasatious  arc  I'uuud  in  dis- 
tant tissues.  .Most  frequent  and  most  piououuced  are 
isubpleural.  subperitoneal,  and  subpericardial  eecliy- 
moses.  but  the  wlu>le  organism  is  deeply  allected,  the 
tissues  being  congested  and  presenting  a  much  darker 
appearance  than  normal.  The  blood  does  not  seem 
to  coagulate  readily  within  cavities  or  interstices  of 
the  body,  unless  death  follows  almost  instantly.  In 
cases  which  live  longer  the  blood  remains  constantly 
in  the  liquid  state  or  coagulates  imperfectly,  and 
then  only  after  being  exposed  to  the  air,  resembling 
in  this  i)articular  the  state  of  that  Huid  observed  in 
conditions  of  asphyxia." 

The  greater  the  proportion  of  the  peptone  part  of 
the  venom,  that  having  a  paralyzing  effect  upon  the 
nerve  centers,  the  quicker  the  death  and  less  the  dis- 
organization and  extravasation  of  the  blood.  Wide 
local  extravasation  commencing  at  the  point  of  in- 
oculation proves  the  excess  of  the  globulin  or  blood- 
disorganizing  element  in  the  venom.  Small  doses  of 
the  poison  produce  comparatively  mild  constitutional 
and  local  symptoms. 

Anomalous  cases  have  been  reported  of  the  late  aj)- 
jiearauce  of  both  local  and  constitutional  signs  of  poi- 
soning after  bites  by  venomous  serpents,  but  these 
must  be  extremely  uncommon. 

Cases  of  severity  which  recover  or  which  live  from 
a  considerable  number  of  hours  to  as  many  days  pre- 
sent quite  characteristic  symptoms.  Prostration  is 
marked,  but  the  mind  will  remain  clear,  except  in 
those  fatal  cases  which  end  in  coma.  The  swelling 
due  to  the  disorganized,  blackened,  incoagulable  ex- 
travasated  blood  soon  spreads  from  the  wound  and 
its  immediate  neighborhood  towards  the  trunk.  In 
a  case  which  the  writer  saw  and  o])erated  upon  suc- 
cessfully not  only  were  the  hand,  forearm,  and  arm 
tensely  swollen,  but  the  shoulder,  pectoral,  and  scapu- 
lar regions  as  well.  The  violet-black,  tense  skin 
seemed  upon  the  point  of  bursting.     Should  the  pa- 


POISOXIOI)   A.\I»    DISSIOCTION    WOT^NDS.  (  ( 

ticiil    sui'vivc   the   iiiiiiic(Ii;il('   coiisl  i  I  ill  ioiiul   olTccIs   (>{ 
the  venom,  Hyniploiris  of  \n\'i'c\\(>n,  siiiiihii-  hoili  locally 
{irid   {'onslilutioiially    lo    (hose   of  dilTiisc   cellular   in 
fl.'ininial  ion,   will    probably  follow.     Ai-cas  of  slouch 
inj!;,  f4anj;i('nc?,  niosl:  oUxm  connnencinji^  in  the  nci^li 
boihood  of  the  bite,  are  indicia! ive  of  the  paHwing  of 
the  venom  poisoning  into  a  more  or  Ichh  diffused  cellu- 
lo-cutaneons  inflanniial  ion.     The  condilion  in  a  reHult 
of  the  retenJion  within  I  lie  lissnew  of  (lie  exiravasated 
disorganized  blood. 

Treatment. — ^The  best  way  to  treat  rattlesnake  bites 
is  to  educate  the  people  likely  to  be  exposed  to  such 
injury.  Sportsmen  and  those  whose  occupation  calls 
them  to  lead  an  out-of-door  country  life  should  be  in- 
formed through  sources  of  general  information,  most 
likely  to  reach  their  e\"es,  how  best  to  take  care  of 
themselves  should  they  be  bitten  by  a  venomous  rej)- 
tile.  Although  it  is  said  that  "a  little  knowledge  is  a 
dangerous  thing,"  yet  in  the  case  of  the  snake-bitten 
victim  the  knowledge  of  how  to  lessen  the  jeopardy 
to  his  life  would  be  (luite  as  valuable  to  him  as  the 
uses  of  the  ''First  Aid''  package  to  the  wounded  sal- 
dier  and  his  comrades  in  the  absence  of  the  immediate 
services  of  a  surgeon.  It  should  be  made  known  that 
a  handkerchief,  piece  of  a  shirt,  rope,  or  any  available 
material  should  be  thrown  around  the  bitten  limb, 
above  the  bite,  and  made  as  tight  as  possible.  This 
is  best  done  by  tying  the  ends  of  the  binding  material 
together  and  then,  after  passing  a  stick  (something 
else  will  answ^er  the  purpose)  under  the  knot,  twist 
the  stick  until  the  ligature  constricts  the  limb  so  as  to 
almost  completely  shut  off  the  circulation  below. 
The  wound  should  be  sucked,  there  being  no  danger 
in  this  procedure  unless  there  be  fresh  wounds  upon 
the  lips  or  in  the  mouth.  It  might  be  the  part  of 
wisdom  for  the  sufferer  himself  or  a  companion  to 
make  a  free  cut  with  a  pocket  knife  into  the  skin  at 
the  site  of  the  snake-bite.  This  would  facilitate  the 
escape  of  any  poison  left  in  the  wound  after  sucking 
it.  Any  danger  from  sepsis  caused  by  the  pocket 
knife  ought  not  to  be  considered,  and  as  to  the  dan- 


78  JioDERN   ii!i:aimi:.\  r  <ii'  W()rM>s. 

jici-  (»l  (UlliiiL;  iiiiii.)ri;uii  paris  iliis  would  Itc  uT  lililc 
luonn'iu  ;  ilu'  prdbabiliiit's  arc  tluit  the  nil  would  be 
iiiadr  t(K)  small  and  loo  shallow,  yet  mucli  y;ood  miglit 
be  done.  W  liiskcv  and  coffee  are  the  only  stimulants 
usually  wiiliin  icacli.  and  these  should  be  given  freely. 
If  a  physician's  services  cannot  be  secured  for  many 
hours  at  the  shortest,  it  would  be  proper  and  perhaps 
necessary  for  the  sufferer,  if  able,  or  his  companion, 
to  loosen  ilic  lijiature  a  little  from  time  to  time  so 
as  not  to  cause  gangrene  in  the  parts  below,  (ireat 
swelling  of  the  limb,  especially  if  the  skin  is  of  a  dark 
"black  and  blue"  color,  ought  to  be  relieved  by  punc- 
tures v.ith  the  point  of  a  knife.  The  kind  of  ])eople 
apt  to  be  bitten  by  »eri)euts  are  not  situated  wliere 
the  services  of  a  physician  are  readily  available,  and 
neither  they  nor  their  friends  will  hesitate  to  do  as 
just  advised  if  they  understand  the  reasonableness  of 
the  practice. 

Little  more  than  just  recommended  can  he  carried 
out  by  the  victim  of  a  snake-bite  or  by  his  friends,  ex- 
cept to  seek  the  services  of  a  physician  as  early  as  pos- 
sible. In  addition  to  the  scientific  surgical  techniiiue 
of  the  practice  just  outlined  as  what  should  be  com- 
mon lay  knowledge,  the  physician  should  place  his 
reliance  upon  the  hypodermic  use  of  large  doses  of 
strychuiue,  repeated  at  short  intervals.  This  drug 
should  be  given  so  as  to  produce  its  physiological  ef- 
fects within  the  limits  of  safety.  Nitroglycerine  may 
be  used,  but  only  in  the  very  early  periods,  because  of 
its  tendency  to  increase  the  blood  extravasations. 
Digitalis  is  too  slow  in  its  effects.  DilVusible  stimu- 
lants are  required  to  overcome  the  cardiac  and  respira- 
tory weakness.  The  injection  into  the  tissues  around 
the  wound  of  a  1  per  cent,  solution  of  pei-manganate 
of  potash  has  proven  serviceable  at  the  hands  of  some 
of  my  professional  friends  who  practice  in  a  section 
where  snake-bites  have  to  be  treated.  A  chromic 
acid  solution  in  water  one-half  of  1  i)er  cent,  has  been 
recommended  by  those  who  have  tried  it. 

For  the  swelling  of  the  limb  multiple  incisions  must 


I'OISONIOI)    AM)    DISSKCTION    WOIJNDH.  TIj 

lie  iii;i(l(',  and  u'licii  lilc  lias  been  spared  some  diiyH, 
and  (lie  swclliiij;  is  excessive,  lliroui^li  und  through 
d)*uJna<i,e  liiis  lo  be  eslablislied  al  as  many  pluccfs  jih 
indicated.  Tliis  was  done  in  a  case  in  my  own  prac- 
tice referred  lo  in  a  preceding  page.  Mnc  .;!  my 
friends  lias  (old  me  ilial  in  a,ddilion  lo  pun-iiir.  -  and 
incisions  he  has  painted  llie  entire  swollen  surl'ac*; 
witli  tincture  of  iodine,  and  as  a  i-esult  lln;  greeu- 
blackish  blood  oozed  through  the  skin  like  profnae 
IKM'spiration.  Tliis  oozing  happens  iji  rare  instances 
witiiout  any  irritation  of  the  skin,  so  il  would  be  good 
]»i'actice  to  try  and  bring  it  about  by  the  use  of  the 
iodine. 

When  a  snake-bite  involves  parts  other  than  the 
extremities,  the  treatment  is  limited  to  stimulation, 
suction  (cupping)  of  the  wound,  incisions,  and  the  sub- 
cutaneous injections  of  the  solutions  mentioned. 

The  after-treatment  should  be  tonic;  iron  and  (jui- 
nine  in  the  way  of  drugs;  good  milk  and  easily  assimi- 
lable foods. 

Animal  Bites. — Lacerated  and  punctured  wounds  in- 
flicted by  the  teeth  of  healthy  animals  are  only  dan- 
gerous because  of  the  severity  of  the  injury,  and  re- 
quire the  same  treatment  as  wounds  of  a  similar  char- 
a,cter  inflicted  by  inanimate  objects.  The  bite  of  a 
human  being  is  quite  different,  however,  because  of 
the  common  presence  of  many  kinds  of  germs  within 
the  mouth.  One  of  the  w^orst  infected  wounds  of  the 
hand  seen  by  me  was  caused  by  the  bite  of  a  man. 
Such  injuries  require  thorough  phophylactic  disinfec- 
tion with  pure  carbolic  acid  and  alcohol;  probably  it 
would  be  best  in  all  cases  to  enlarge  the  wound. 

The  hite  of  a  dog  suspected  even  of  "being  mad"  should 
be  cauterized  thoroughly  with  pure  nitric  acid.  Re- 
cent experiments  upon  animals  have  proven  that  after 
inoculation  with  the  germs  of  hydrophobia,  if  the 
wound  of  the  experiment  be  thoroughly  cauterized 
with  nitric  acid,  90  per  cent,  of  the  animals  escape  in- 
fection. In  addition  to  this  treatment  I  would  recom- 
mend a  visit  to  some  institution  for  the  scientitic  car- 
rving  out  of  Pasteur's  treatment. 


80  MODKUN  tui:atmi:nt  ov  wounds. 


OHAl*lU<:ii  Xl\. 
SPECIFIC     WOUND   INFECTIONS— ERVSll'Kl.AS. 

Uudcr  llir  head  of  specific  wound  iufections  we 
tlassity  tlmse  suri^ical  wound  diseases  in  w'hich  a 
wound  is  followed  by  ceilain  more  or  less  marked  clas- 
sical local  and  couslilutional  dislurbances.  For  the 
production  of  these  diseases  there  must  be  a  wound 
or  point  of  inoculation,  which  may  be  of  slight  moiueni, 
and  be  completely  healed  before  constitutional  symp- 
toms develop;  or  unhealthy  repair  precedes  and  ac- 
companies the  appearance  and  course  of  the  general 
systemic  poisoning.  The  infection  or  poisoning  is 
microbic  or  bio-chemical.  The  diseases  under  consid- 
eration are  separate  and  distinct  from  those  mentioned 
when  treating  of  interferences  with  wound  repair 
caused  by  the  presence  of  germs. 

EuYsirELAS  is  a  specific  infectious  disease  due  to 
the  entrance  into  the  lymphatics,  small  veins  and  cap- 
illaries of  the  streptococcus  crysiiiclotus,  first  discovered 
by  Fehleisen,  who,  in  his  work  on  the  Etiology  of  Ery- 
sipelas, published  in  1883,  tells  how  he  proved  con- 
clusively that  erysipelas  is  due  to  the  infective  proper- 
ties of  the  streptococcus  named  after  him.  From  little 
pieces  of  skin  removed  from  patients  suffering  with 
erysipelas  he  made  cultures  on  peptonized  gelatine. 
From  these  cultures  he  obtained  a  streptococcus  with 
which,  after  culturing  many  times  (thirty  generations), 
he  inoculated  eight  persons,  seven  of  whom  developed 
erysipelas.  This  is  as  conclusive  proof  that  this  par- 
ticular germ  is  the  cause  of  the  disease  under  consid- 
eration as  that  any  other  known  germ  is  the  cause  of 
a  classified  disease.  The  bacillus  develops  in  the  skin, 
subcutaneous  cellular  tissue,  and  sometimes  in  the 
mucous  membrane.  The  growth  of  the  cocci  produces 
an  inflammation  which  tends  to  spread  rapidly,  and  as 
a  result  of  the  growth  ]U'oducts  or  toxins  are  formed 
which  produce  constitutional  symptoms  sometimes  of  a 
^•iolent  typo.     Clinical  o^■idence  has  absolutely  ]»roven 


SJ'IOOIFIO    WOI/NI^    INH'HO't'IOXS — KItVHl  I'lOLAS.  «  1 

the  contaj^iousness  of  oryHipclaH  uud  Uw.  mode  of  en- 
tmiice  of  the  oonlugiiim  ia  always  tlirougli  some  breach 
ol  Mill-race.  Alllioiigii  in  tlie  laboraloiy  I  he  idenlily  of 
the  erywipelas  HU-eplococcuw  with  I  hat,  of  (he  Htrepto- 
coccus  of  su[)[)\ii*atioii  is  apparently  established,  yet 
clinically,  erysipelas  is  followed  by  erywii^elas  unless 
the  greatest  care  is  exercised  by  I  he  suigcon  in  passing 
from  the  dressing  of  a  wound  infected  with  erysipelas 
to  that  of  a  healthy  wound.  Whereas  no  such  danger 
is  encountered  iu  the  treating  of  several  wounds,  one 
after  another,  when  one  or  more  are  the  subject  of 
suppuration  caused  by  an  infection  of  the  streptococ- 
i',us  pyogenes.  The  greatest  danger  in  this  latter  is 
that  a  healthy  wound,  free  from  suppuration,  may 
become  infected  as  the  result  of  a  shiftlessness  of 
•antiseptic  details  upon  the  part  of  the  surgeon.  The 
older  writers,  and  even  many  of  our  modern  ones,  con- 
sume considerable  space  in  describing  how  unhygi- 
enic conditions,  the  crowding  together  of  many 
wounded,  bad  ventilation,  poor  sewerage,  debilitated 
general  health,  all  predispose  to  the  development  of 
erysipelas.  This  is  only  true  in  that  such  conditions 
lead  to  a  laxity  of  enforcement  of  now  well  known  and 
proven  precautionary  measures  essential  to  keep  out 
the  invasion  of  many  preventable  diseases;  all  of 
which  has  been  well  illustrated  by  the  lack  of  fore- 
thought and  executive  ability  displayed  by  those  in 
authority,  and  having  in  keeping  the  lives  of  soldiers 
in  many  mobilizations,  and  in  the  camps  of  those  en- 
gaged in  active  field  service.  This  has  been  as  well 
illustrated  at  the  close  of  the  century  in  our  late  war 
with  Spain,  both  in  the  camps  at  home  and  in  the  field 
in  Cuba,  as  in  the  campaigns  of  Napoleon  in  the  early 
.part  of  the  century,  and  in  the  Crimea  in  the  middle 
part  of  the  century.  x4.1though  science  has  advanced 
and  the  cause  and  prevention  of  many  diseases  has 
become  w^ell  understood  during  the  nineteenth  cen- 
tury, and  particularly  during  the  last  twenty-five 
years,  yet  little  improvement  has  been  made  in  sub- 
verting human  selfishness  among  politicians,  militarv 
and  civic,  to  the  common  cause  of  humanity. 


82  MOUKUN    TUKATMENT    OF    WOUNDS. 

Si/htpiuiiit,. — The  disease  is  usual Iv  sudtU-ii  iu  onset, 
llierc  beiug  an  elevaliuii  of  tcnipciaiuie  lo  lOi  F.  to 
105°  F.,  with  chills  or  even  a  li^or.  There  may  be  nau- 
sea aud  vouiitiu};  as  observed  in  other  acute  diseases. 
At  the  end  of  about  twenty-four  hours  a  brif^bt  red 
rash  makes  its  appearance  around  about  and  spread- 
iny;  away  from  a  wound  which  may  be  apparently 
healed,  insignificant  in  character,  or  of  considerable 
size  and  importance.  Most  commonly  the  wound  is,  as 
has  been  described,  "unheallhy""  ami  not  doing  well. 
The  rash  is  characteristic,  disappearing  momentarily 
on  pressure  and  having  a  sharp  and  easily  defined  bor- 
der. It  does  not  gradually  fade  away  from  a  center  of 
great  intensity  of  color  to  a  pale  border.  Pressure  is 
painful  and  there  is  intense  burning  over  the  area  of 
the  rash.  The  infectiveness  of  the  disease  is  well  shown 
by  the  enlargement  of  the  lymphatic  gland  nearest  the 
inoculated  wound  and  the  tendency  of  the  infection  to 
spread  along  the  lymphatic  channels  to  the  next  neigh- 
boring glands.  Occasionally  the  rash  is  ^■ery  pale, 
especially  in  anemic  patients;  more  commonly  the 
color  is  dark  or  cyanotic.  The  tenser  the  tissue  the 
paler  the  rash  and  less  the  swelling.  On  the  other 
hand,  in  loose  tissues  the  rash  is  distinct  in  color  and 
the  swelling  is  very  nmrked.  and  it  is  most  often  in 
loose  cellular  tissue  that  occasional  complication  devel- 
ops, i.  e.,  suppuration.  Vesicles  and  bulhe  are  com- 
mon, forming  as  the  result  of  intense  edema.  These 
bulhie  usually  dry  up,  and,  in  fact,  except  in  very  much 
debilitated  subjects,  suppuration  or  a  more  general 
breaking  down  of  tissues  and  the  development  of  gan- 
grene is  rare.  The  rash  varies  in  its  duration  from  a 
f<;w  days  to  several  weeks,  usually  one  week  to  ten 
days.  Kelapse  is  common.  There  is  a  continuous 
elevation  of  temperature,  which,  however,  is  of  little 
importance  unless  it  reaches  above  104-  F. 

After  a  few  days  the  type  of  fever  changes  from  that 
f.f  a  sthenic  form  to  one  do^noting  debility.  Delirium 
is  common  and  most  often  observed  in  erysipelas  of  the 
scalp  and  face.  As  the  rash  subsides,  desquamation 
follows.     Complications  are  sometimes  observed.     In 


SPEOIFU;   WOUND    1  M('JO<;'J'I<).N'S — EltYSU'lOI.AS.  H'.j 

facial  erysipelaa  the  rash  may  Hpiead  and  iuvolve  the 
raucouH  ineiubi'Hiie  of  tlie  air  i>aHsageH,  iieceKHitaliri},' 
oi)ei-a.l,ive  measures  to  prevent  death  by  Hullocjjtion. 
{Secondary  involvement  of  tissues  other  than  the  skiu 
is  brought  about  by  an  invasion  of  auch  tissues  from 
an  attack  of  the  skin  covering  them.  As  for  example, 
interior  of  joints,  llie  peritoneum,  the  [dcura  and  ili(i 
meninges  of  Ihe  bruin.  However,  this  is  not  always 
so,  as  the  writer  has  seen  examijles  of  secondary  in- 
volvement of  the  pleura,  brain,  and  peritoneum  in 
cases  where  the  disease  began  in  the  extremities. 
Probabl}^  all  such  cases  are  examples  of  blood  poison- 
ing, the  germs  being  carried  and  lodged  through  the 
circulation  into  distant  tissues  and  organs,  setting  up 
a  secondary  inflammation. 

Phlegmonous  Erysipelas  is  a  serious  and  often- 
times dangerous  form  of  disease  resulting  from  the 
invasion  of  the  subcutaneous  cellular  tissues,  and 
intermuscular  septa  by  the  streptococcus  erysipelatus. 
This  inflammation  results  in  more  or  less  sloughing 
of  the  skin  and  subcellular  tissues.  The  clinical  pic- 
ture of  this  disease  varies  little  from  that  of  the 
cellulo-cutaneous  inflammations  caused  by  a  penning 
up  of  the  products  of  suppuration  in  infected  wounds, 
as  described  in  former  pages  when  writing  of  the  ne- 
cessity of  drainage  in  deep  seated  suppuration.  The 
inflammation  usually  begins  in  a  wound  of  an  ex- 
tremity. There  is  rapid  swelling,  with  discoloration 
of  the  skin,  which  suffers  secondarily,  the  inflamma- 
tion starting  beneath  and  spreading  toward  the  sur- 
face. The  color  of  the  skin  is  that  of  a  deep  red,  which 
gradually  fades  into  the  health}^  skin  instead  of  the 
abrupt  border  of  cutaneous  erysipelas.  The  swelling 
soon  becomes  tense,  brawmy,  and  painful,  and,  as  in  the 
cutaneous  varieties,  bullae  often  form  and,  unless  relief 
is  given  by  the  surgeon,  local  areas  of  gangrene  develop 
at  the  points  of  greatest  tension.  The  forerunners 
of  such  a  condition  are  observed  as  areas  of  dark  blue 
color  of  the  skin  with  edema  and  doughiuess;  some- 
times an  indistinct  fluctuation  is  present.  Through 
the  openings  afforded  by  the  at  first  circumscribed 


84  M(>i>i:kn  tukatmknt  oi'  woinhs. 

areas  of  y;angr«.'Ue  lailu-i-  a  prurust*  (listliarj;;e  of  pus 
takes  place,  lu  eases  where  there  has  been  great  leu- 
sioL,  with  late  relief  either  l»,v  (he  surgeon  or  unaided 
nature,  extensive  sloughs  of  the  skin  form.  These 
nia.v  expose  the  muscles,  the  enveloping  meuibranes 
111'  joiuts,  and  in  cases  where  the  original  injury  oi>ened 
up  intermuscular  planes,  extensive  desiructlctn  of  mus- 
cles and  even  bone  results.  It  is  especially  in  the 
latter  condition,  as,  for  instance,  where  erysipehis  com- 
lilicates  a  deep  seated  wound,  that  the  rather  slow 
formation  of  sloughs  and  escape  of  pent  up  pus  results 
in  blood  poisoning.  In  such  a  case  the  pus,  instead  of 
seekiug  the  subcutaneous  cellular  tissue  early,  often 
se  nis  to  elect  lirst  traveling  between  muscles  and 
close  to  bones. 

The  constitutional  symptoms  are  marked  by  pain, 
fever,  early  depression,  especially  if  there  is  profuse 
suppuration  and  sloughing.  Unless  there  is  early 
relief  of  pent  up  products  of  the  inflammation,  blood 
poisoning  with  or  without  secondary  infections  and 
suppuration  in  distant  organs  or  tissues  is  apt  to 
follow. 

Treatment. — P>ery  case  of  erj'sipelas  developing  or 
brought  into  a  hospital  should  be  isolated  and  every 
knowm  principle  of  antiseptic  surgery  carried  out  in 
the  treatment  of  the  case.  In  examining  and  dressing 
the  wounds  sterilized  rubber  gloves  should  be  worn 
and  the  naked  hand  should  under  no  circumstances 
come  in  contact  with  the  wound,  body,  or  bedding  of 
the  patient.  If  this  precaution  is  adhered  to  the  dan- 
ger of  infecting  others  will  be  lessened.  It  will  not  do 
to  rely  upon  wearing  sterile  rubber  gloves  at  opera- 
tions, and  at  other  times  (after  handling  a  case  of 
erysipelas),  in  the  office,  private  residence,  or  dispen- 
sfiry,  when  doing  little  things,  use  the  naked  hands. 
True  it  is  that  the  hands  can  be  sterilized  so  that  tliey 
will  be  ordinarily  safe,  but  it  is  also  true  that  the  germ 
of  erysipelas  is  very  poisonous  and  hard  to  wash  away. 
The  writer  recalls  very  vividly  a  personal  experience 
in  Which  he  carried  erysi})elas  from  a  case  of  erysipelas 
of  the  scalp,  following  a  minor  operation  in  private 


Hl'KCAhnC   WOUND   INFEG'I'lONS       KIIYHII'IOLAH.  Sjj 

pi-acLi<<',  (()  foiii-  ollici-  individualH,  orx;  in  lios|)il.iil, 
three  in  (licit.'  hornes.  Every  i>re(;uution  Heenujd  to 
have  been  taken,  and  exactly  where  the  leak  occurred 
is  nol  known  to  I  his  d;iy,  but  tli<'re  w;ih  a  leak,  find 
al(lionji,li  no  fiilalily  reHuKcd,  much  ncedlcHS  siilfering 
did. 

I'recautionH  against  infecting  others  should  be  taken 
by  uurs'^s  as  well  as  doctors.  It  is  best  always  to  have 
a  special  nurse  for  such  cases.  In  spite  of  a  prejudice 
against  it,  there  is  no  more  grateful  or  curative  an 
agent  in  the  treatment  of  cutaneous  erysipelas  than 
moist  cold.  Cloths  wrung  out  of  a  cold,  mildly  anti- 
septic solution  are  best  for  application,  and  the  wound 
of  inoculation  should  be  treated  upon  its  merits  after 
the  rules  laid  down  for  the  treatment  of  infected 
wounds, — drainage  with  antisepsis. 

Numerous  cures  for  cutaneous  erysipelas  have  been 
offered,  and  some  are  beneficial.  xVmong  them  the 
covering  of  the  inflamed  area  by  an  ointment  of 
ichthyol  in  lanoline,  one  dram  to  one  ounce.  A  solu- 
tion of  thiol  in  water,  20  to  40  per  cent.,  is  recom- 
mended. This  is  x)ainted  over  the  infected  skin  as  well 
as  for  some  distance  beyond.  Thiol  is  less  objectiona- 
ble than  ichthyol  because  of  the  bad  smell  of  the  latter, 
and  it  is  reported  to  be  almost  a  specific.  Abortive 
measures  by  scarifications  and  the  use  of  strong  anti- 
sceptics  are  valueless  to  abort;  at  least  that  is  the  per- 
sonal experience  of  the  writer.  The  lead  and  opium 
wash  is  a  soothing  application,  and  is  useful  and  grate- 
ful to  the  patient  when  the  wound  is  insignificant. 
Shallow  or  deep  incisions  ought  to  be  made  when  there 
is  tension  sufficient  to  threaten  the  life  of  any  area  of 
skin.  Tonics,  and  especially  strychnine  and  the 
muriated  tincture  of  iron,  are  of  value. 

Gellulo-cutaneous  erysipelas  demands  surgical  inter- 
ference. An  incision  or  incisions  to  the  bottom  of 
the  wound  of  infection  must  be  made,  and  early. 
Sloughing  of  the  skin  should  be  anticipated  by  in- 
cisions before  the  vitality  of  the  tissues  is  more  than 
threatened.  Free  drainage  should  be  established  and 
maintained  by  copious  and  frequent  antiseptic  irriga- 


80  MODERN  THEATMENT  OF  WOLNOS. 

tiuns.  and  the  part  sboultl  be  c'livchtpeil  in  lai-j;e,  moist 
amisejilic  liiessiii^s.  Touics.  sliuuilaiils.  and  fi)i'Led 
feeding  are  essential  lo  maintain  strength  and  resist- 
ing jiuwcrs.  (\>ld  ai»i)lications  are  harmful  in  this 
form,  as  tending  to  inc-rease  the  danger  of  slonghing. 
Secondary  comijlications  may  rciniic  incision  al  a 
distanee. — they  should  be  made  early.  I'snally  care- 
ful dressings,  skin  grafting,  or  transplantation  of 
large  Haps  will  sullice  for  the  repaii-  of  sjjacf's  of  raw 
surfaces  nm-overed  by  sloughing.  Occasionally,  but 
rarely,  amimintion  is  re(iuii-ed.  It  should  never  be 
done  duiing  an  acute  stage  of  infection.  Death  rarely 
follows  acute  cutaneous  erysi}K'las.  the  mortality  be- 
ing less  than  5  per  cent.,  except  among  old  people  and 
children,  when  it  is  larger.  The  phlegmonous  variety 
should  be  rarely  fatal  when  treated  ]>roi)!  ily.  There 
will  be.  howevei'.  occasional  deaths  in  s])ite  of  oni'  best 
directed  eil'orts. 


TKTANUS.  S7 


CHAPTER  XV. 

TETANUS. 

This  is  a  disease  due  to  a  specific  wound  iuf<icliou, 
and  is  characterized  by  painful  tonic  contractions 
of  muscles  of  volunlary  motion,  be^inninf^  with  those 
of  the  jaw  or  neck,  and  spreading-  to  the  muscles  of 
the  trunk  and  extremities.  The  germ  causing  tetanus 
was  first  discovered  in  1884  by  Nicolaier,  but  it  was 
not  until  1881)  that  bacteriologists  succeeded  in  mak- 
ing pure  cultures.  To  Kitasato,  the  distinguished 
Japanese  scientist,  belongs  this  honor. 

In  order  to  comprehend  more  fully  the  essential 
factors  in  the  causation,  clinical  histor}',  and  treat- 
ment of  tetanus  it  may  be  well  to  refer  somewhat 
to  the  results  of  bacteriological  studies  of  the  tetanus 
bacillus.  The  bacilli  are  slender  and  straight,  of 
slight  motility,  and  ijresent  on  one  end  an  enlarged 
or  pin-headed  extremity.  This  enlarged  end  is  the 
spore  or  offspring  of  the  bacillus.  The  germ  is  an- 
aerobic in  character,  i.  e.,  cannot  live  in  the  presence 
of  oxygen;  grows  best  at  the  temperature  of  the  body, 
having  slower  developing  powers  at  lower  tempera- 
tures, and  below  56°  F.  ceases  to  grow.  Dried  spores 
live  indefinitely,  but  are  killed  in  a  few  minutes  if 
exposed  to  moist  heat  at  the  temperature  of  boiling 
water.  "They  withstand  in  the  moist  condition,  for 
an  hour,  a  temperature  of  80°  C,  a  property  which 
was  utilized  by  Kitasato  to  destroy  other  bacteria 
in  obtaining  pure  cultures  of  the  tetanus  bacillus. 
The  spores  survive  and  preserve  their  virulence  for 
ten  hours  in  5  per  cent,  carbolic  acid;  they  are  killed 
in  fifteen  hours.  They  are  not  killed  by  putrefactive 
bacteria." — (Welch.) 

It  is  instructive  to  note  that  in  experimental  tetanus 
the  period  of  incubation  after  inoculation  of  an  ani- 
mal varies  from  a  few  hours  to  as  many  days,  and 
although  this  is  also  true  of  man,  yet  infrequently 


SS  MODERN     rKi:AlMi:N  r    of    Wt^TVUS. 

mauy  days  or  eveu  weeks  elapse  before  the  syniptoius 
nf  tetanus  develop  after  infection.  The  rapidity  of 
I  he  (U'M'ldpiiu-nt  of  li'tanic  symptoms  after  infection 
must  depend  upon  the  dose  and  the  miscibility  of  tin; 
tissues  at  the  point  or  surface  of  inoculation  with 
the  bacilli  so  as  to  produce  the  toxins  or  ptomaines 
whose  action  upon  the  si)inal  coi-d  produce  the  pe 
(  uliar  nniscular  spasms. 

Notwithstanding  the  iciaiius  harillus  is  widely 
distributed,  more  especially  in  warm  climates,  having 
been  discovered  in  almost  all  kinds  of  outdoor  dirt, 
manured  ground,  etc.,  yet  because  of  the  anaerobic 
character  of  the  germs,  their  growth  in  wounds  is 
mostly  confined  to  those  in  which  they  are  carried 
deeply  into  the  tissues  at  the  time  of  the  |»ro(lnction 
of  the  wound. 

Before  the  cause  of  tetanus  was  discovered  the 
clinical  history  of  the  disease,  and  possibly  the  treat- 
ment, was  as  well  taught  as  to-day,  but  because  of 
ignorance  as  to  the  causative  factor  many  fancied 
theories  were  advanced  in  this  disease,  as  in  most 
others,  relative  to  rather  mysterious  nervous  influ- 
ences, climatic  changes,  etc.,  being  responsible  for  its 
production. 

Tetanus  may  follow  injuries  and  wounds  of  one 
part  of  the  body  as  well  as  another,  although  the  feet 
and  hands,  and  especially  the  former,  are  most  often 
subjects  of  i)unctured  wounds  likely  to  be  infected  by 
the  tetanus  bacillus, — punctured  and  lacerated 
wounds  leaving  foreign  bodies,  and  those  likely  of 
contamination  with  street  dirt,  garden  dirt,  and  ma- 
nure; for  exam])le.  splinters  from  boards  on  old  fences 
or  those  lying  around  on  the  ground;  old  rusty  nails, 
l>arts  of  4tli  of  -Inly  explosives  "set  off"  in  public 
streets  oi*  in  the  house  yard.  Every  year  a  large 
numl>er  of  cases  of  tetanus  are  reported  following 
little  wounds  from  j»ar1s  of  the  caps  of  toy  pistols. 
In  these  last  cases,  proliably  the  germs  were  on  the 
liands.  and  were  carried  into  the  tissues  along  with 
the  pieces  of  jjistol  caps. 

Tetanus   has   l»een    known    fo    follow    all    kinds   of 


TK'I'ANUS.  89 

(>])('i  ill  ion  vvouikIs,  ImiI  lliis  uiis  jtrior  lo  I  lie  iikxIcmii 
coinpi'cliciisioii  of  jnitiH('j)li(;  hikI  Mseplic  surgery.  Of 
course,  in  emergeucy  surgery  it  might  be  iinpossible 
to  prevent  infection  by  the  tetanus  bacillus,  but  in 
operations  of  elcclion  there  (;oul(l  be  no  excuse.  As 
in  erysipelas,  I  Ik;  wound  of  (entrance  of  the  infection 
may  be  so  insignilicant  that  some  cases  have  been 
called  idiopathic,  but,  with  our  present  knowledge, 
we  must  insist  that  no  icound,  no  tetanus.  In  this 
connection  it  may  be  proper  to  refer  to  the  case  of 
a  bull  dead  of  tetanus  of  whose  Ilesh  several  persons 
ate;  three  were  seized  with  tetanus  and  two  died. 
This  observation  was  made  manj^  years  ago,  1857,  by 
Betoli.  Tetanus  is  found  in  the  new  born  infant, 
infection  occurring  through  the  cord,  also  in  the  pu- 
erperal woman,  or  after  abortions.  These  differ  in  no 
w^ay  from  the  common  varieties  of  tetanus. 

Clinical  History. — Tetanus  is  either  acute  or  chronic. 
The  acute  form  is  ushered  in  from  a  few  hours  to  three 
w^eeks  after  infection.  Most  commonly  two  or  three 
days  elapse  betw^een  the  time  of  infection  until  the 
first  symptoms  develop.  Then  the  patient  notices  a 
difficulty  in  opening  the  mouth,  with  more  or  less 
cramping  in  the  muscles  of  mastication.  The  neck 
may  be  a  little  stiff  and  the  patient  attribute  the 
W'hole  difficulty,  which  in  the  beginning  is  usually 
mild,  to  "taking  cold.''  In  some  hours  the  symptoms 
become  aggravated  and  the  cramping  of  the  muscles 
of  mastication  becomes  so  severe  that  the  patient 
cannot  open  the  jaw,  or  can  at  best  only  slightly  sepa- 
rate the  teeth  (lock-jaw).  The  muscular  contractions 
are  painful,  usually  excruciatingly  so,  and  fluids  are 
swallowed  with  great  difficulty.  The  muscles  of  the 
face  and  back  of  the  neck  soon  become  involved, 
causing  a  peculiar  expression  called  risus  sardonicu-s. 
Sometimes  before  the  face  muscles  are  involved,  those 
of  the  trunk  and  extremities  exhibit  spasmodic  con- 
tractions with  cramping  pains.  As  in  experimentally 
produced  tetanus  in  animals,  the  muscles  of  the  parts 
nearest  the  point  of  inoculation  are  first  aft'ected.  so 
in  man  the  first  muscular  spasms  may  appear  near  the 


ItO  Mul>i:UN    TUKATMli.NT    (»F    WiU'NPS. 

\\(iuii(i.  Tlic  iiiuscuhir  ((Hii  laci  ions  sdoii  Ikn'ouii' 
jiliH(is(  colli  inuoiis;  swallowing  is  painlnl  and  dilli- 
(ult,  and  ol'lcn  brinjis  on  fresh  nmsciilar  spasms,  in 
fact  anv  stiniulns,  as  a  snddt'n  noise,  cold  draft,  or 
any  iniiant  oi-  \()lnnlar.v  cll'oii,  may  do  tills.  The  back 
inusclfs  may  conn  ad  so  as  lo  produce  opisthoto- 
nus. I^ateral  and  forward  c(»n(or(ions  are  sometimes 
observed.  Excei)t  durinj;-  unusual  muscular  contrac- 
tions, the  patient  lies  on  his  side  with  the  head  drawn 
back  and  the  spinal  arch  exajijieraied.  There  is  per- 
fect consciousness.  There  is  relent  ion  of  urine  and 
tlie  bowels  refuse  to  act  because  of  the  contraction  of 
the  sphincters.  The  urine  is  albuminous.  Most  com- 
monly there  is  fever  from  the  beginning  which  may 
be  (luite  high.  More  rarely  there  is  no  fever,  but 
usually  the  fever  of  itself  is  not  alarming. 

Diaphoresis  is  almost  always  a  feature  of  the  dis- 
( i'.se  and  occurs  always  after  severe  convulsions. 
There  is  little  sleep  without  drugs.  Attempts  at 
swallowing  may  bring  on  a  renewal  of  convulsions; 
the  face  may  become  cyanotic  because  of  the  spasm 
preventing  respiration  or  causing  a  closure  of  the 
glottis.  In  the  intervals  of  spasms,  the  face  is  anx- 
ious and  pale.  Death  is  generally  the  result  of  ex- 
haustion or  spasm  of  the  muscles  allowing  of  respira- 
tion. Very  high  temperatures  are  common  a  short 
time  before  and  after  death;  a  fatal  termination 
occurs  most  often  before  the  end  of  the  fifth  day  and 
can  occur  within  twenty-four  hours.  In  the  chronic 
form  the  symptoms  occur  later,  after  infection,  and 
are  milder  in  character.  There  is  little  or  no  fever. 
The  onset  of  the  symptoms  follow's  in  the  second  or 
third  week  after  the  injury.  The  clinical  picture  is 
quite  similar  to  that  of  acute  tetanus,  only  not  so  im- 
pressive. There  are  remissions  and  even  intermis- 
sions of  all  symptoms.  Gradual  improvement  takes 
place  and  the  i»atient  recovers.  Death  may  take 
place. 

Head  Tetanus. — A  very  dangerous  though  rare  form 
of  tetanus  follows  infe(;tion  of  areas  supplied  by  th(i 
cranial    nei-ves,    especially    in    I  he    neighborhood    of 


TIOTANUH.  91 

supraorbital  bnmcIicH.  Tlicjc  is  i)iiiiil.yHis  of  ili<; 
facial  nerve  witli  triwiiiuH,  and  at  tiinen  great  dilliculty 
in  ywallowing.  A.  maniacal  frenzy  is  HonietinieH  ob- 
served. Tlierc  iDay  be;  more  or  less  general  tonic 
muscviliir  spiisins. 

Diaynosis. — There  siioiild  ]ut  lilllc  diniciilly  in  m;ik- 
ing  a  diagnosis  of  tetanus.  It  lias  to  be  differentiated 
from  inflammatory  diniculties  about  the  mouth  ov 
temporo-maxillary  joint.  These  can  be  detected  by 
inspection  and  palpation,  and  in  case  of  the  joint  being 
affected,  this  is  most  commonly  unilateral.  In  tetanus 
there  is  an  early  rigidity  of  the  muscles  of  the  neck. 
In  severe  strychnine  poisoning  there  are  usually  com- 
plete periods  of  intermission  (found  also  in  chronic 
tetanus).  The  muscles  of  the  hands  are  rarely  in- 
volved in  tetanus,  in  strychnine  poisoning  they  com- 
monly are.    The  spasms  of  hydrophobia  are  clonic. 

The  prognosis  is  bad  in  acute  tetanus,  but  the  favora- 
ble signs  are  late  onset,  long  duration,  lengthening  of 
intervals  between  attacks  of  muscular  cramps.  Sta- 
tistics seem  to  prove  that  an  attack  coming  on  undi^r 
ten  days  after  infection  only  4  per  cent,  recover ;  after 
ten  to  fifteen  days,  27  per  cent.;  after  fifteen  to 
twenty  days,  45  per  cent. — (Rose.) 

Treatment. — Careful  antisepsis  is  of  the  greatest 
importance  as  a  prophylactic  measure,  and  besides  all 
punctured  and  other  kinds  of  wounds  likely  to  have 
carried  the  germs  of  tetanus  into  the  tissues  should 
be  freely  opened,  all  foreign  bodies  removed;  cleansed 
by,  first,  using  peroxide  of  hydrogen  or  pyrozoue,  be- 
cause of  the  anaerobic  character  of  the  bacillus;  then 
thoroughl}'  antisepticized  with  pure  carbolic  acid; 
wash  this  away  with  95  per  cent,  alcohol.  Tincture 
of  iodine  or  a  saturated  solution  of  permanganate  of 
potash  may  be  employed.  All  such  wounds  should  be 
treated  on  the  open,  free  drainage,  antiseptic  plan. 
After  the  development  of  the  symptoms,  the  same 
antiseptic  plan  of  treatment  should  be  followed  as 
far  as  practicable.  All  irritation  should  be  avoided 
and  absolute  quiet  enforced;  liquid  food  may  be 
swallowed,  or  failing  in  this,  a  tube  may  be  introduced 


92  MODIMtN    TUKAT-MKNT    Ul'    \Vl»LNl>S. 

tliritugh  the  uose  and  suitable  noiii'ishment  poured 
Ihrou^'h  it  into  the  stomach.  Sedatives,  such  as 
thloral.  bring  some  relief  to  the  patient,  but  it  is 
doubtful  whether  or  no  a  patient  was  ever  saved  by 
drugs.  When  these  drugs  are  used  they  should  be 
given  so  as  to  produce  their  physiological  effects  an«i 
control  the  convulsicuis.  No  stated  doses  can  be 
given.  The  giAing  of  sedative  drugs  is  recommended 
chietly  as  a  humanitarian  prjictice.  Chloroform  is 
useful  to  control  spasms. 

The  bi'lief  of  the  writer  is  thai  in  (he  working  out  of 
the  antitoxin  treatment  of  tetanus  lies  our  only  hope 
of  a  cure.  In  experimental  medicine  much  has  been 
learned  and  accomplished,  but  practically  in  the 
treatment  of  the  human  sntTerei-  from  tetanus  little 
has  been  accomplished. 

The  serum  to  date  is  simply  an  immunizing  agent 
and  not  an  antitoxin  or  agent  capable  of  counteracting 
the  effects  of  toxins  already  in  the  blood.  Immunizing 
injections  should  be  given  in  suspicious  wounds,  and 
in  the  beginning  of  tetanus  the  antitoxin  as  made 
should  be  tried  with  the  hope  of  its  modifying  the 
symploms. 


si'M'Tk;  i;i,ooi)  rftisoNixo.  IK'. 


OHAPTEJ;  XVI. 

TREATMENT  OF  SEP'I'iC   r.LOOl)   I'OISOXING. 

By  septic  infection  we  mean  a  general  diHea«e 
caused  by  tlie  entrance  into  the  circulation  of  the 
germs  of  suppuration  or  t'he  products  of  thc«se  gei'ms. 
The  germis  gain  entraiuce  at  the  point  of  inoculation 
either  through  an  external  wound,  or  being  present 
in  the  circulation  are  enabled  to  act  deleteriously  be- 
cause of  some  local  depression  or  want  of  resistance 
upon  the  part  of  the  tissue's. 

The  clinical  picture  varies  in  accordance  with  the 
kind  of  infection  or  blood  poisoning.  When  the  action 
of  certain  germs  results  in  the  rapid  production  of  a 
toxin  or  poison  the  absorption  of  which  causes  a 
depression  to  the  vital  centers,  followed  by  a  greater 
or  less  interference  with  the  natural  functions  of  the 
emunctories,  a  most  sierious  condition  is  brought 
about.  The  outcome  will  depend  upon  the  quality  of 
the  toxin  (commonly  called  a  chemical  substance  or 
ptomaine),  and  the  amount  of  the  poison  absorbed. 

TJie  Unusual  Form  of  Septicemia — Sapremia. — Fortu- 
nate'ly  this  form  of  blood  poisoning  is  rare  and  its 
source  not  difficult  to  recognize,  being  more  commonly 
tbe  result  of  the  decomposition  of  clofjs  in  the  uterus 
aft^er  abortion  or  full  term  pregnancy.  It  is  found  as 
the  result  of  decomposition  of  clots  in  wounds,  rarely 
those  of  a  subcutaneous  kind.  The  infection  is  char- 
acterized b}"  a  rapid  rise  of  temperature,  103°  F.,  to 
105°  F.  There  may  or  may  not  be  a  chill.  The  tem- 
perature continues  high  and  symptoms  of  vital  de- 
pression develop.  The  sldn  becomes  clammy,  the 
tongue  di*y,  the  pulse  rapid,  the  second  heart  sound 
indistinct. 

Diarrhea,  may  develop.  The  patient  dies  in  from 
two  to  five  days.  This  is  the  picture  seen  when  the 
expectant  plan  of  treatment  is  practiced.  Quite  an- 
other picture  is  presented  if  rational  surgical  princi- 
ples are  early  adopted. 


!)4  Moiii:i;.\    iici^aimkn  r  oi'   woinds. 

Treatnieut  consists  in  the  removal  of  all  (Uh-oiu 
poslnir  matt'iials  and  the  use  of  copious  irrigations, 
with  tlu-  uiaiutcnancc  of  j;ood  tlraina^^*.  Kt'coverv 
is  iH-ouii>t,  provided  the  source  of  the  toxins  is  ree- 
oj^uizable,  and  can  be  reached  before  there  is  gre.it 
viial  depression.  It  is  to  be  remembered  that  al- 
though the  surface  temperatuiH*  may  not  be  high, 
possibly  sub-noruKil,  because  of  the  condition  of  the 
skin,  the  rectal  temperature  will  always  be  found  at 
least  several  degrees  above  normal.  Many  times  after 
abdominal  operations  this  ra]>idly  fatal  form  of  blood 
poisoning  has  developed,  t'he  condition  being  attrib- 
uted to  shock,  when  had  the  rect'al  temperature  been 
taken  so  soon  as  bad  symptoms  appeared,  possibly 
lives  might  have  been  saved  by  an  attempt  to  remove 
the  cause  of  infection. 

Even  though  the  focus  from  wliich  the  intoxicant 
started  may  be  reached,  usually  little  good  will  re- 
sult. So  large  a  surface  for  the  aibsoiivtion  of  toxins 
is  presented  within  the  abdomen  that  tlie  prairie  fire 
like  speed  with  which  the  poison  spreads  admits  of 
such  an  overwhelming  dose  of  the  toxins  being  ab- 
sorbed, that  vital  centers  are  paralyzed  and  death 
is  almost  inevitable.  The  spread  of  the  infection 
over  the  peritoneal  .surface  may  be  -so  rapid  that  foAV 
naked  eye  changes  are  observable  in  that  membrane. 

The  treatment  is  preventative,  and  may  be  stated  by 
formulating  one  or  two  good  rules.  After  a  celiot- 
omy try  never  to  leave  within  the  abdomen  any  fluid 
or  clotted  blood.  In  most  eases  this  can  be  done  by 
a  careful  hemo«tasis  and  the  'sp'onging  away  of  all 
blood  from  the  peritoneum  without  or  after  irriga- 
tion. 

Many  times  raw  surfaces  can  be  covered  by  peri- 
toneal flaps,  and  stitches  introduced  at  well  select'3d 
sites  will  faliut  off  exposed  areas  and  at  the  same  time 
minimize  oozing.  Often,  however,  it  is  impossible  to 
prevent  some  oozing  and  at  times  rathei*  free  bleeding 
from  i*aw,  torn  surfaces.  In  such  cases  drainage  must 
be  established  and  maintained  until  the  oozing  be- 
comes serous. 


SKi'Tii'  r.Mioi)  roisoMN*;.  95 

ir  Die  bleeding  is  Jr<'(',  i  he  (ii;rni;i;.'('  is  coiiihiiicd 
vvilli  pi-cssui'ic  l),y  iisiii;;  f^iiiizc  packing.  'J'lic  Mikulicz, 
iodolonii  gauze  drain  m  '('lie  hcsl  i'ov  tiii.s  pnipose,  ])(i- 
oanse  a  piece  of  gauze  oaunot  be  left  beliiiul  after 
what  was  supposedly  a  complete  removal  of  all  gauze. 
Besides  (be  pr(;'Hsure  uimn  and  drainage  of  the  parts 
involved  can  ho  gradually  reduced,  and  in  the  cai-ry- 
ing  out  of  this  there  is  less  local  disturbance  and  pain 
than  when  separate  pieces  of  gauze  are  pemoved,  each 
of  which  is  in  direct  contact  with  the  peritoneal  sur- 
faces. 

A  word  about  iodoform.  It  has  a  property  that  no 
other  material  is  known  to  possess,  and  is  of  great 
A'alue  in  the  preventive  treatment  of  all  forms  of 
blood  poisoning.  It  takes  only  a  few  hours  after 
the  applicatiom  of  iodoform  to  a  fresh  wound  surface 
for  the  formation  of  a  deep  zone  of  leucocytes  and  con- 
nective tissue  corpu'scles  held  within  the  meshes  of 
fibrinous  trabecular — an  exaggerated  fibrino  plastic 
exudate.  This  rapidly  formed  exudate  represents  the 
developmental  stage  of  a  protective  granulation  tissue 
formation. 

Suppose  an  abscess  deeply  situated  and  partly  in- 
accessible containing  highly  infective  pus,  and  so  sit- 
uated that  it  is  impossible  after  incision  to  immedi- 
ately thoroughly  remove,  disinfect,  and  change  the 
character  of  its  secreting  surfaces.  The  protective 
property  of  iodoform  when  applied  to  a  cut  surface 
in  such  a  case  is  undeniable.  Likewise  in  the  incis- 
ions for  the  evacuation  of  tuberculous  abscesses 
whose  sources  and  channels  of  descent  cannot  be 
fJwroughhf  curetted,  and  therefore  should  not  be  cu- 
retted at  all,  iodoform  forms  a  safeguard  against  a 
mixed  infection  of  the  tuberculous  lesion  from  with- 
out, as  well  as  a.  protection  against  a  tuberculous 
spread  to  the  tissues  involved  in  the  wound. 

The  property  iodoform  has  of  causing  the  rapid 
formation  of  a  protecting  fibrino  plastic  exudate  is 
likewise  of  great  value  when  iodoform  gauze  is  used 
as  a  packing  and  drainage  material  in  intra-abdomi- 
nal work.    Should  infective  germs  gain  entrance  from 


!M;  MOOKIiN    TREATMENT    OF    WuUNDS. 

wilbuui  along;  the  iwlDform  gauze  drain,  and  this 
occasionally  happens  as  the  result  of  carelessness  or 
in  spite  of  gi-eut  care,  any  infi^-tion  of  the  i)eriloneuni 
would  he  merely  a  local  atfair,  i.  e.,  one  with  the 
fornuiiiou  and  discharge  of  i)us  without  manifest  dan- 
gei-^us  constitutionaJ  symptoms. 

Pi/cniia. — In  several  ])recc<ling  (•hai)(ers  the  ti-eat- 
UK'nt  of  Avound  inlVctions,  sciiticcniias,  aw  met  with 
under  a  numerous  variety  of  conditions,  has  been  dis- 
cussed within  the  limits  in(ende<l  in  these  pages. 
Thei-e  is  one  particularly  important  form  of  blood 
poisoning  whicli  re(]uires  more  ela])oration  and  is 
called  pi/cmia.  It  has  been  defined  and  recognized 
by  uKKlern  surgeons  as  a  "general  infective  disease 
which  ai-ises  from  the  entrance  into  the  blood  of  the 
constituents  of  infected  pus.  It  is  distinguished  from 
other  septic  infective  diseases  by  the  development  of 
multiple  abscesses  in  various  organs  and  by  an  inter- 
mittent fever."  Of  course  from  the  earliest  times  it 
was  recognized  that,  in  inflammatory  conditions  char- 
acterized by  the  formation  of  jius,  in  some  cases  mul- 
tiple abscesses  fonned  and  Hiat  the  iype  of  the  dis- 
ease was  a  dangerous  one.  The  pus  was  .«!aid  to  be 
*'in  the  blood." 

AMien  ])us  germs,  or  infected  thrombi,  originating 
in  a  wound,  or  from  an  inflammatory  levsion  within  the 
body,  enter  the  circulation  cei'tain  symptoms  result. 
These  vary  in  character  and  intensity  and  depend 
upon  the  localities  at  which  the  elements  are  arrested. 
The  amount  and  frequency  of  detachment  and  en- 
trance into  the  circulation,  eiflier  from  an  original 
focus  or  from  a  metasta.sis.  determines  the  nature  and 
seriousness  of  secondary  infective  procf^ses.  Al- 
though it  is  usual  for  the  starting  point  from  which 
a  pyemia  develops  to  be  an  infected  suppurating 
wound  of  a  longer  or  shorter  duration,  sometimes  this 
focus  is  (piite  insignificant  as  has  been  observed  when 
discussing  poisoned  wounds. 

^Sj/niptoms. — The  disease  is  almost  alway.^  ushered 
in  by  either  a  violent  chill,  or  chilly  sensations  and 
chattering  of  the  teeth.    The  chill  mnv  last  onlv  a  few 


Kioi"i'i(;  lu.ooi)  roisoNiNG.  !>7 

niijiiilcs,  ail  lioin',  or  ]>ossiI)Iy  ]<>ni^<n:  Tlio  tempera- 
Uii'o  j'iscs  .Hc^vora]  dogrctiw,  in  many  caHen  aw  hi{:;h  mh 
105°  F.  In  from  eight  to  twenty-four  hours  the  fever 
disappears;  the  temperature  may  then  be  subnormal. 
There  is  marked  depression.  The  chills  recur,  some- 
times  several  lin  a  day.  With  each  recurrence  the 
general  depression  increases,  the  wkin  takes  on  a 
leaden  'hue,  the  features  become  pinched.  There  often 
is  an  increasing  irregularity  as  to  the  time  of  the 
chill.  High  fever  i«  frequently  followetl  by  a  marked 
remission  or  a  isubnormal  temperature. 

The  uisual  accompaniments  or  results  of  fever  due 
to  blood  poisoning  are  obsei-ved,  viz.:  Thirst,  lows  of 
appetite,  emaciation.  During  the  rise  of  temperature 
there  may  be  only  a  little  mental  disturbance.  In 
some  cases,  however,  tbe  nocturnal  delirium  is 
marked.  The  type  of  the  fever  simulates  in  most 
cases  an  intermittent  malaria,  in  others  it  may  be 
not  unlike  a  pernicious  malaria.  The  irregular  chills 
are  probably  the  result  of  the  intermittent  entrance 
of  pus  into  the  circulation.  Not  long  after  the  irreg- 
ularity of  the  chills  is  well  established,  clinical  evi- 
dence of  infiamma'tion  of  joints,  bones,  muscles;  or 
internal  organs,  as  lungs,  liver,  spleen,  and  brain,  will 
be  detected,  and  if  the  pati'ent  lives  long  enough  ab- 
scesses will  develop  in  one  or  more  of  these  parts. 

The  parotid  gland  is  not  infrequently  attacked,  and 
the  writer  has  observed  this  most  often  as  an  accom- 
paniment to  a  suppurative  inflammation  within  the 
abdomen.  With  the  development  of  the  chills  the 
wound  takes  on  an  unhealthy  condition,  the  granula- 
tions become  pale,  the  discharge  thin  and  scanty: 
the  parts  around  about  swell,  the  skin  is  pale  and 
brawmy.  All  repair  ceases.  The  prognosis  is  grave, 
but  not  hopeless,  and  depends  upon  the  employment 
of  early  rational  treatment. 

Treatment. — Possibly  the  writer  can  best  illustrate 
the  subject  by  referring  to  one  or  two  cases  wbich 
have  been  of  value  as  object  lessons  to  him.  A  cow- 
boy was  wounded  by  the  accidental  discharge  of  a 
44  cal.  Colt's  revolver,  carried  in  irs  holster  at  his 


98  M(»i>i:ijN    ruKATMiON  r  t»i-   \v<ir.\i»s. 

ng:Ll  hip.  Tile  luilki  eut^ivd  the  rig'bt  leg  at  ii  paiut 
a  litrli'  lu'liMv  and  midway  bet^'oen  the  liead  of  the 
Mhiila  and  ilu'  liltia.  and  passed  dii-cctly  dowiiwards 
ihrouji'li  the  luusclos  on  (he  aiinriui'  i  iWio  lilmhir  n- 
gion,  crossed  (lie  aid<lo  joini  iii  ironi  ul'  the  external 
malleolus,  and  Idducd  unc'u  i-  i  lie  skin  on  the  outer  side 
of  the  f()(d  near  (he  base  of  the  liflh  metatarsal  bone. 
The  man  had  been  brought  to  the  hosjiital  in  a  wagoii^ 
a  distance  of  fifty  miles,  and  arrived  about  twelve 
hours  after  the  injury,  the  wonnd  having  I'eeeivetl 
prai'tically  no  attention. 

The  parts  were  eleau.sed.  tlie  luillei  ex(rae(ed,  and 
an  antiseptic  dressing  applied.  Although  suppura- 
tion developed,  everything  went  along  fairly  well  until 
the  .'ixth  day.  At  this  time  the  man  had  a  severe 
chill  followed  by  a  high  fever.  The  next  day  there 
was  another  chill.  The  wound  stopped  secreting,  the 
leg  began  to  swell.  The  chills  recurred,  the  tempera- 
ture reaching  sometimes  as  high  as  105°  F.  On  sev- 
eral occasions  there  was  a  subnormal  temperature 
following  a  marked  elevation.  Delirium,  especially 
at  night,  was  almost  constant.  An  interesting  phase 
of  the  delirium  was  the  patient's  desire  for  the  pos- 
sess/ion of  his  gun  in  order  that  he  might  <'fix''  me. 
He  had  been  a  bad  man  in  Texas.  This  was  illustra- 
tive of  the  usual  querulousne.«s  which  accompanies  the 
delirium  of  pyemia.  The  swelling  extended  from  the 
leg  to  the  thigh.  The  scrotum  swelled.  The  skin  of 
(he  leg  and  thigh  was  pale  and  glistening,  the  super- 
ficial veins  were  prominent.  The  pulse  became  fast 
iind  feeble.  ITe  commenced  to  cough  and  the  physi- 
cal signs  of  fluid  in  the  pleural  cavity  were  made  out. 

A  fluctuating  swelling  fonned  in  the  left  axilla. 
The  breath  had  a  characteristic,  sweet,  fres'h  hay 
odor.  On  the  thirteenth  day  after  tlie  injury  the  man 
died.  A  ])ost-mortem  examination  showed  that  pus 
had  traveled  through  the  torn  muscles  up  and  down 
the  leg  between  the  bones.  The  veins  were  partly 
obstructed  by  clots.  There  was  pus  in  the  left  pleural 
cavity,  as  well  as  in  the  axillary  swelling.  Being  n 
subordinate,  mv  duties  had  consisted  in  the  extrac- 


noil  of  llic  IhiIIcI  :iii<I  I  Ik-  iii;ikiii<;  of  I  lie  post -iiioiii'iii 
exaiimiiuMon,  Ijut  I  obsci'ved  tlie  (reatinont.  It:  liuii 
(•ouwislcd  ill  ill  liMiipIs,  iiHiKilly  nnsiircM'HHinl,  to  wasJi 
oul  Mic  loiij:,'  (rack  of  IIk;  Imllcl.  vvilli  an  ajitinaytu- 
soliilion;  IIk.^  inlTodncfion  of  draiiiH  iiilo  both  woihhIh, 
and  tlie  I'ocal  aipplicalioii  (o  I  he  Ic^-  and  llii<;li  of  iiiosi; 
of  the  remcdiow  for  eelluto-cutaiicons  inllaiiiiiiation, 
I'ecomuiieii'dcd  in  Naiphey's  ''Surgical  Thei'a|>euticH."' 
Quinine,  iron,  and  whiskey  had  it)een  given  in  full 
do'»es. 

Within  a  week  after  this  man's  death  it  so  happened 
tliat  an  lexaetly  similar  case  came  under  my  care. 
During  a  few  mioments  of  hilarity  'between  dances  at 
a  frontier  party,  a  drunken  cowboy  amused  himself 
by  shooting"  alternately  into  the  ceiling  and  floor.  The 
last  shot  struck  the  floor,  but  not  until  after  the 
bullet,  a  44  cal.  Colt's,  had  followed  exactly  the  same 
track  as  dn  the  preceding  case.  The  man  w^as  put  into 
a  wagon  and  brought  to  the  hospital,  a  distance  of 
forty -five  miles.  After  scrubbing  the  leg  and  foot 
they  were  bathed  in  a  1  to  1,000  solution  of  bichloride 
(this  drug  as  an  antiis'eptic  had  just  been  inti'oduced 
into  surgical  practice).  Fe'airing  infection,  a  Gouley 
urethral  dilator  was  passed  into  the  wound  as  a  guide 
and  a  free  incision  made  in  the  long  axis  of  the  bullet 
track  abont  its  middle  third.  Dradnage  tubes  were 
introduced  and  an  antiseptic  dressing  applied.  Irri- 
gations were  used  daily  and  the  wound  repaired  with 
little  sui)pu'ration  in  a  short  while. 

As  an  lillustration  of  chronic  pyemia,  rather  infre- 
quently met  with,  the  following  case  recently  seen 
will  serve  as  an  example:  A  young  man  30  years 
of  age  was  attacked  in  August,  1898,  with  a  right- 
sided  pleuro-pneumonia.  This  ended  in  a  sacculated 
empyema  of  the  low^er  part  of  the  pleural  cavity. 
For  wrecks  the  pus  Avas  allowed  to  stay  undisturbed. 
Nature  finally'  tried  to  bring  about  relief  and  the  ab- 
scess ruptureki  into  a  bronchus.  A  large  quantity  of 
putrid  pus  was  coughed  up.  Following  this  there  was 
improvement.  Foi'  several  weeks  the  continued  fever. 
.  sw^eating,  and  loss  of  appetite  were  much  modified. 


!<•()  MuKKlJN    TUEATMENT    oi'    \V«HM>S. 

Tbcu  ilic  r-.iisiii','  of  ]nis  i-i'iisiil  aiul  ai  iho  same  time 
I  he  (.•oiisiiiiitional  .syiiipluins  bi'came  worse.  Uphill 
drainage  uuiild  uut  sullke;  the  opening  in  the  bron- 
chus closed.  The  patient's  general  condition  beeame 
much  run  down.  The  oiu-ning  into  the  bronchus 
(losed  and  rcoptMHMl  several  liuics,  ilie  i)atient  losing 
ground  continuously.  Numerous  superficial  a-bscesses 
formetl.  The  skin  on  the  extremities  exfoliated  in 
several  places,  i^^pecially  on  t'li<'  hands  and  fivt,  letiv- 
ing  raw,  bleeding  surfaces.  The  temperature  varied 
daily  fri»m  normal,  sometimes  sub-uomial,  to  two  or 
tour  degrees  above  normal.  The  tongue  was  usually 
dry,  ai)petite  poor;  bowels  souietimes  quite  loose. 
Emaciation  had  become  extreme.  There  were  several 
bad  bed  sores.  The  mind  wandered;  exhaustion  was 
extreme.    The  pulse  was  mpid  and  feeble. 

The  appearance  of  this  individual  when  seen  by  me 
in  December,  1898,  was  pitiable.  At  this  time  there 
was  no  drainage.  It  wa«  suggested  that  a  dependent 
opening  be  made  by  means  of  a  trocar;  slipping  i\ 
drainagx?  tube  through  the  canula  so  that  drainage 
might  be  established  without  shock.  The  procedure 
was  not  urged  as  the  case  seemed  hopeless,  death 
being  apparently  only  a  day  or  so  off.  It  has  ibeen 
learned  that  nothing  was  done,  yet  the  patient  lived 
about  three  weeks  longer. 

Treatment. — Pyemia  ought  never  to  develop  from  a 
wound  which  can  be  managed  from  its  early  history 
according  to  the  principles  of  antiseptic  surgei-y.  Oc- 
casionally cases  will  be  met  with  in  which  from  the 
nature  of  the  wound  it  may  be  impossible  to  prevent 
the  development  of  suppuration.  Likewise  satisfac- 
tory drainage  cannot  always  be  had,  yet  the  great 
majority  of  wounds,  if  seen  sufticiently  early,  can  be 
protected  against  infection.  If  infection  is  suspected 
or  has  already  developed  in  a  wound  and  remained 
local,  the  infected  focus  can  be  disinfected  and  drained 
so  as  to  ])rev<Mit  systemic  poisoning. 

Cases  I  and  II  may  be  briefly  discussed  in  illustra- 
tion: In  the  former  a  probably  infected  wound  was 
received  for  treatment.     TTad  disinfection  and  drain- 


sioP'I'k;  i'.i.ook  poisoning.  l<ii 

age  been  ean"Jed  out  aw  in  Iho  lattei'  lifc  in  preHUiiiJild"- 
that  the  result  woukl  liavo  been  favorable.  JmiiMMli 
ately  after  tlie  con  mi  en  cement  <yt  the  HyniptoniH  of 
pyemia,  the  only  ralioiial  courKe  to  pui-Hiu;  under  Himi- 
lar  circum, stances  would  be  to  lay  the  track  of  (li<; 
bullet  open,  going  to  the 'bottom  of  every  di»cov(M'iihl<; 
pocket  or  recesH. 

Having  done  tliis  tlu'  vviiolo  vvoiiiid  should  bo  I  lior- 
oughly  disinfected  by  some  strong  antiseptic,  prefera- 
bly pure  carboilic  acid,  95  per  cent.,  which  is  best 
washed  away  by  alcohol,  and  then  either  a  normal 
salt  solution,  or  if  pi-eferred,  a  1  to  2,000  solution 
of  ibi chloride  of  naercury  in  watei'  may  be  used  for 
irrigation.  The  wound  should  be  lightly  packed  with 
iodoform  gauze  and  over  this  a  moist  antiseptic  dress- 
ing applied.  In  many  cases  of  beginning  pyemia  such 
a.  line  of  practice  will  localize  the  infection.  In  more 
complicated  conditions,  for  example,  in  involvement 
of  bones,  the  infection  being  of  the  nature  of  an 
acute  osteomyelitis,  sufficient  openings  in  the  bone 
should  be  made  with  chisels  and  trephine  to  admit 
of  a  free  use  of  the  Voikmann  sharp  spoon,  followed 
by  a  similar  disinfection,  drainage  and  dressing.  No 
case  of  infective  (suppurative)  cellulo-cutaneous  m- 
flammation,  whatever  its  exjciting  cause,  should  be 
treated  other  than  iby  the  free  use  of  the  knife,  and 
the  maintenance  of  good  drainage.  Pus  may  not 
always  be  found  but  tension  is  relieved.  Metastatic 
abscesses  should  be  opened  as  soon  as  recognizable, 
and  their  cavities  disinfected  and  drained.  Of  course 
secondary  abscesses  of  the  lungs,  liver,  kidneys,  and 
spleen  offer  difficulties  of  recognition  and  treatment, 
yet  there  is  no  reason  w^hy  they  should  not  be  at- 
tacked when  the  vitality  of  the  patient  admits. 

Chronic  pyemia  requires  the  same  surgical  treat- 
ment as  the  more  acute  infections.  Insufficient  drain- 
age of  a  pus  cavity  was  the  cause  of  death  in  Case 
III.  The  writer  has  seen  a  number  of  cases  of  em- 
pyema, w%ich  terminated  unfortunately;  not  because 
of  the  acute  virulence  of  the  disease,  but  rather  from 
a  more  or  less  prolonged  intoxication,  either  septi- 


lUL'  MoDRKN    TIJKA'l'M  i;N'r    oK    \V()rNI>S. 

roiuii-  or  pyiMiiic.  Nmilv  nil  of  Ihe^e  cases  will  ii- 
i-i>vfi'  if  drained  eailv,  and  ii  is  not  a  (juesliou  ol 
terlinitiiio  (rib  resec-lidii  or  not),  but  one  of  free  and 
sntlitient  di'aiiiaji,i'  fiiv  ilu*  particular  case,  rphill  or 
anv  oilier  ini'on»]>lctc  drainaji'e  of  a  se]»tif  roms  is  not 
only  uusatisfactorN    Imi   danj^crous. 

If  in  any  case  of  }»ycniia  coniplicali-d  hy  a  septic 
phlebilis  it  is  pos'sible  to  discover  al  wliai  point  or 
points  ligaturi^  may  be  applied  to  the  infecletl  veins 
so  as  to  prevent  central  poisouinji;  from  detached 
sejitie  clots,  such  practice  is  loR'ical.  The  dilTiculty  is 
in  bein^-  able  (o  detennine  the  limit  of  Ihe  dol  forma- 
ti<vn  towards  the  center  of  the  circulation.  Ami)uta- 
lion  may  sometimes  be  jmstitiaible  when  an  attempt 
to  save  an  extensively  infcctiMl  extnMnity  would  too 
g-reatly  jwvpardize  life. 

The  medicinal  treatment  of  all  f(trnis  of  si']»tic  Idood 
poisomnfi:  is  supportive.  Iron,  iiuinine,  and  strych- 
nine should  be  g-iven  in  liberal  doses.  Alcohol  in  the 
form  of  whiskey  or  brandy  is  thought  by  many  to  be 
of  gre-at  value  and  to  act  as  an  antitoxin.  ]Maybe  it 
is,  but  alcoliol  is  a  depivssor  of  the  nervous  centei*s, 
and  except  when  administered  for  some  ishort-lived, 
express  pui-pose,  a®  preliminary  to  a  surgical  opera- 
tion for  its  courage  stimulating,  and  anesthetic  ef- 
fects, had  better  be  given  with  caution.  Copious 
quantities  of  water  internally  and  externally,  are  of 
unquestionable  value  in  aiding  the  elimination  of  poi- 
s(mous  i»roducts.  Every  effort  should  be  made  to 
sustain  the  strength  of  these  patients  by  the  giving 
of  as  much  easily  digested  food  as  possible.  It  is 
often  advantageous  to  admini'ster  nourishment  and 
water  per  rectum. 


(JOMI'OUNI)    l<'HA(!'r(!Iti;S   <)!•   IjUSti    I'.OSKH.  U))' 


CHAPTER  XVII. 

COMPOUND  FKACTUltES  OF  LONG  BONES. 

In  cases  of  coiiii)ouiid  fracture  the  fate  of  a  limb 
and  often  a  life  (Iciu'iids  iijioii  the  care  with  which 
the  wound  is  handled  from  the  time  immediately  fol- 
lowing the  accident  until  the  dressings  and  splints 
are  applied.  Independent  of  the  purely  surgical  treat- 
ment of  the  injury,  great  importance  must  be  at- 
tached, in  bad  cases  accompanied  by  severe  shock,  to 
the  means  employed  in  combating  shock  and  prevent- 
ing increased  trauma  and  irritation  in  the  transpor- 
tation of  the  patient  to  his  home  or  a  hospital.  Given 
a  case  of  compound  fracture  sufficiently  grave  in  char- 
acter to  produce  dangerous  depression,  the  first  aim 
of  the  surgeon  should  be  the  administration  of  re- 
storatives. Usually  it  is  necessary  to  rip  or  cut  the 
clothing  in  order  to  inspect  the  site  of  fracture.  If 
hemorrhage  is  going  on,  this  should  be  controlled 
by  direct  pressure  applied  by  means  of  antiseptic 
gauze  and  a  bandage.  Failing  these,  any  freshly 
washed  and  ironed  material  may  be  substituted. 
Spurting  vessels  may  be  secured  by  artery  clamps, 
which,  when  the  urgency  admits,  must  be  washed  or 
dipped  in  some  strong  antiseptic.  However,  the  sur- 
geon should  not  stand  on  antiseptic  ceremony,  but 
\mmed\atdy  stop  a  free  hemorrhage  by  direct  digital 
pressure  or  the  application  of  the  pocket-case  artery 
forceps.  In  serious  injuries,  accompanied  by  free 
hemorrhage,  the  immediate  control  of  the  bleeding- 
is  of  the  first  importance.  If  the  source  of  the  hemor- 
rhage is  not  to  be  reached  by  the  ordinary  first  aid 
means  just  mentioned,  an  elastic  or  some  improvised 
tourniquet  should  be  applied  to  the  limb  above  the 
injury  at  a  point  where  the  main  artery  can  be  com- 
pressed with  the  least  constricting  force.  Attention 
is  directed  to  this  last  matter,  because  it  has  been 
observed  that  in  compound  fractures  resulting  in  a 
8 


104  MODEHN    TUKAIWIKN  T    Ol'    W(»rNl»S. 

tli'vitali/atioii  ol"  (he  jtarts  bt'l<i\\  liic  iiijuiv,  if  auy 
I'lasiic  i<niiiii<|Ufi  had  been  railici-  lii^liilv  aitplifil 
and  allowed  i<t  rt-inaiii  a  coiisidcralilc  liiiic  l)i't"<»r('  the 
di'viializi'il  i)art  was  rniiovcd  1>\  (tpciaiioii,  lliat  the 
Haps  of  tlu'  wound  made  l»v  ihc  sui-;i,('on  sl(»n}:;ht'd. 
It  slionld  alsd  lie  ifuicndit'i-cd  ihai  when  lut'ssurc  is 
made  directiv  nuht  Mil'  wouiid,  wide  extra  vasal  ion 
niav  follow  ;  likewise  it  infective  }j;enus  have  already 
enteied  the  wound  piior  to  the  sui-jicon  seeinj;  the 
case  and  the  ajiplication  (d'  his  compresses,  these 
germs  nniy  be  forced  into  the  tissues  by  the  extrava- 
satinfj  bh)od  current.  A  wound  which  niiglit  have 
been  nnidi'  safe  by  tlie  en)ph)yment  of  antiseptics 
would  possibly  in  tliis  way  be  rendered  impossible  of 
sterilization.  Therefore,  for  this  reason,  and  also 
when  marked  extravasation  of  blood  is  p,oinfj  on  with 
little  external  hemorrhagic  it  is  safe  to  presume  that 
a  large,  deei)ly  situated  branch  or  a  main  vessel  has 
been  w^ouuded.  Under  these  circumstances  a  tourni- 
quet should  be  used  as  just  su<j:gested.  Except  for  the 
combating'  of  shock  and  the  contr(d  of  excessive  bleed- 
ing, the  duty  of  the  surgeon  who  sees  the  patient  for 
the  tirst  time  is  to  apply  a  temporary  antiseptic  dress- 
ing without  any  attempt  upon  his  part  to  explore  or 
handle  the  wound.  The  usual  signs  of  fracture,  to- 
gether with  the  presence  of  a  wound  at  or  near  the 
site  of  crepitus  and  increased  mobility  and  change 
of  axis,  are  sufficient  for  the  diagnosis.  Nothing  <;ni 
be  gained  at  this  time  by  an  exploration,  digital  oi- 
insti-umental.  and  much  damag<'  can  be  done,  yet  how 
common  to  learn  of  the  otliciousness  of  some  doctors 
(usually  hangers  on)  called  u]»on  to  care  for  those 
seriously  injured,  when  carried  into  the  nearest  drug- 
store. The  wiiter  has  treated  many  cases  which  had 
been  fingered  and  ])robed  with  and  without  attempts 
at  antisepsis.  This  harmful  and  useless  interference 
having  been  done  at  places  and  under  circumstances 
that  no  profit  could  have  l»een  made  of  any  knowledge 
gained.  He  is  c<»nlident  that  much  unnecessary  suf- 
fering, and  occasionally  death,  even  in  this  oilr 
boasted  era  of  surgei-v.  I'esults. 


(JOMI'OUND   KUArrURIOS   OT^   LONG    l'.(tNi;S.  l<l."j 

11'  a  bone  is  proliiidiiij;  il  is  no!  wiH(*  lo  i-cjiIju-c  il; 
until  uf'ter  llic  cjirernl  use  oT  aii(is('i)licH,  Jind  ii.s  IIiIh 
can  rarely  he  done  hclorc  (lie  pjiliml  is  moved  lo  Ids 
home  or  a  li(»s|»il;il,  (he  best  jii-aclice  is  to  iipply  I  lie 
temporary  dressing-  without  interference.  In  this  con- 
nection it  may  be  well  to  take  notice  of  the  ''First 
Aid,"  or  Ksmareh  package,  in  us(*  in  our  army  and  in 
the  German  army.  It  contains  in  a  small  (!om])a8S 
the  essentials  of  a  primary  occlusive  antiseptic  dress- 
ing; can  be  carried  in  the  surgeon's  bag  or  ambulance 
box  without  danger  of  contamination,  and  keeps  al- 
most indetinitely.  The  usual  i)recautions  recom- 
mended in  transporting  cases  of  simple  fracture  of  the 
lower  extremities  to  their  place  of  permanent  treat- 
ment must  be  painstakingly  followed.  When  the  frac- 
ture is  of  an  upper  extremity  the  sufferer  can  walk  or 
ride  sitting  up,  unless  the  nature  of  the  fracture  con- 
traindicates,  the  wounded  member  being  supported 
in  a  sling. 

Before  proceeding  to  the  examination  and  treat- 
ment of  the  fracture  everything  should  be  gotten 
in  readiness  as  we  do  for  any  surgical  operation,  and 
especially  one  where  we  know  that  a  slip  in  antiseptic 
technique  may  be  followed  by  most  serious  conse- 
quences. In  hospitals  everything  is  at  hand,  but  in 
private  practice  this  is  exceptionally  so  in  emergency 
surgery.  If  the  surgeon  has  had  time  to  secure  a  roll 
of  sterilized  instruments,  so  much  the  better;  other- 
wise, he  must  either  boil  his  instruments  in  some 
suitable  vessel;  perhaps  he  may  have  a  sterilizer  at 
hand,  or  they  may  be  placed  in  a  1-20  solution  of  car- 
bolic acid  and  allowed  to  remain  in  this  while  prepa- 
rations are  progressing;  his  other  armamentarium  is 
supposedly  always  ready  for  use.  Plaster  of  Paris 
in  bulk  or  bandage  should  be  secured.  The  prepara- 
tions detailed  in  a  former  chapter  are  arranged  ac- 
cording to  the  circumstances  and  surroundings  of  the 
case.  Two  solutions,  one  of  carbolic  acid  1-20.  and 
the  other  of  bichloride  of  mercury  1-500.  must  be  at 
hand;  from  these  weaker  solutions  can  be  readily 
made.    A  piece  of  rubber  sheeting  or  table  oilcloth  of 


106  MODERN    TREATMENT    Or    WOUNDS. 

sullicieut  size  shoiikl  \>v  \\;islu'(l  in  soup  aud  water, 
sjxmged  off  with  alcohol,  and  thi'n  douched  with  a 
solution  of  bichloride  of  mercury  1-1,000.  Everythiuir 
bcinj^-  in  readiness,  the  i)atient  should  be  auesthetixed. 
After  the  clothes  are  removed,  he  is  placed  upon  the 
operating  table,  bed,  or  floor  in  such  a  position  as 
to  allow  of  the  easiest  mauiinilalions  uj)on  the  part 
of  the  surgeon  and  his  assistants.  The  rubber  sheet 
must  be  put  under  the  injured  part  so  as  to  drain  away 
fluids  into  some  bucket  or  i)an,  and  also  arranged  to 
shut  off  the  wound  from  contamination  by  contact 
with  other  parts  of  the  l»ody.  bedding,  etc.  Of  course 
the  most  painstaking  care  is  ex<n-cised  by  everyone 
taking  part  to  keep  the  hands  surgically  clean.  The 
temporary  dressing  is  removed,  if  one  has  been  aj) 
plied,  and  the  wound  protected  by  covering  it  with  a 
sufficiently  sized  piece  of  moist  antiseptic  gauze.  The 
greater  part  of  the  extremity  above,  around,  and  be- 
low the  wound  is  now  well  scrubbed  with  soap  and 
water,  shaved,  and  then  douched  off  with  a.  1-1,000 
solution  of  bichloride  of  mercury.  The  area  about  the 
wound  is  now  sponged  with  alcohol  and  then  douched 
again  with  a  1-1,000  bichloride  solution.  Sterile 
towels,  or  "clean"  towels  after  being  wrung  out  of  a 
1-1,000  bichloride  solution,  are  wrapped  around  the 
limb  above  and  below  the  injury  and  spread  about  so 
as  to  prevent  contamination.  It  is  safer  for  the  sur- 
geon to  wear  rubber  gloves  previously  sterilized  and 
kept  protected  and  ready  for  use.  These  gloves  should 
be  drawn  over  the  hands  after  the  latter  have  been 
properly  washed,  and  not  removed  until  the  limb  has 
been  prepared  for  examination  and  operation.  The 
gloves  can  then  be  pulled  off  either  by  an  assistant 
using  an  antiseptic  towel  to  prevent  coutaminaliou 
of  his  own  hands,  or  by  some  one  whose  duty  cannot 
in  any  way  bring  his  hands  in  contact  with  the  sur- 
geon's or  as.<sistant's  hands,  the  wound,  or  any  article 
of  possiblo  service  in  the  operative  technique.  In 
hospital  practice  it  is  always  safer  and  should  be 
practicable  for  surgeon  and  assistants  to  wear  sterile 
rubber  gloves  in  all  opcmtions.    Those  taking  part  in 


(lOMl'OlJND    FltA<;TIIItI')S   OK    Li)S*i    liONIOS.  107 

t,b(;  prepJiJ")!  i(»iiH  I'oi-  an  opera  I  ion  ciiaii;^'!!!^  ^Ionch, 
with  aiilisc])!  ic  jii-ccaulion.s,  Ix.'foi-c  lalviiif^-  pari  in  i  Ih' 
oporathc  procedure  itweir.  TJieHe  r(;lJiieineiit.H  are  iioL 
absolutely  essential,  but  when  i)racticecl,  are  in  touch 
with  the  techiii(ine  of  the  most  sueccHsfiil  surj^^eons. 
One  may  well  wonder,  when  (casually  viewing  the 
hands  of  some  general  practitioners  and  surgeons  as 
we  meet  them  in  consultation  or  socially — would  it 
be  possible  for  such  hands  to  be  so  washed  as  to  be 
surgically  clean!  For  all  such  we  urge  the  use  of 
sterile  rubber  gloves. 

TREATMENT. 

We  now  come  to  the  line  of  treatment  to  be  fol- 
lowed, and  this  must  depend  upon  what  our  examina- 
tion discloses. 

The  Simple  Cases. — In  a  large  percentage  of  cases 
the  wound  through  the  soft  parts  is  of  itself  not  of 
great  moment,  neither  is  the  injury  to  the  bone;  the 
danger  to  be  feared  is  infection.  In  order  to  reduce 
this  danger  to  a  minimum  the  following  practice  has 
given  the  greatest  success:  When  the  bone  is  pro- 
truding it  should  be  thoroughly  disinfected  with  a 
strong  antiseptic.  If  apparently  clean  after  irriga- 
tion, it  should  be  sponged  over  carefully  with  a  1-500 
solution  of  bichloride  and  then  irrigated  with  a 
weaker  solution.  Any  dirt,  coal  dust,  or  grease  which 
may  have  gotten  onto  and  apparently  almost  into  the 
broken  bone  should  be  removed  mechanically  with 
forceps  and  gauze  saturated  in  alcohol.  The  bichlo- 
ride sponging  (1-500  solution),  and  later  irrigation 
with  a  much  weaker  solution  (1-2,000  or  even  1-1.000), 
will  make  the  protruding  bone  end  free  from  active 
pathogenic  germs.  If  the  skin  wound  is  too  small  to 
allow  of  thoroughly  digital  exploration,  a  suitable 
incision  is  made  and  the  injury  examined  by  the 
finger,  any  loose  detached  fragments  of  bone,  foreign 
bodies,  and  dirt  are  removed,  and  if  the  examination 
discloses  a  limited  soft  part  injury  the  operation  is 
completed  by  irrigating  the  wound  throughout  with  a 
1-1,000  bichloride  solution,  and  then  reducing  the  pro- 


108  MODERN    TREAIMKNT    (»F    WolNDS. 

liiKiiiif^  end.  Al'ici-  this  rcdini  ion  aiiolhci-  irri^uai  i<in 
\villi  ji  l-4.(MMi  hiihloi  idt'  soliilidii  is  advisabU'.  One 
or  more  lulibiT  drains  arc  iiitrodiucd,  a  moisl  antisep- 
tic drt'ssiu<,'  a{)[)lied,  and  iln-  limb  immobilized.  For 
the  i)uri)ose  of  immobllizalion  no  material  answers 
(jnite  so  well  as  plaster  {>f  Paris.  A  cast  may  be  made 
to  sunonnd  tlu;  limb,  jiossibly  cnttinj;  a  window  over 
the  wdund  ari-a  for  the  dressing  and  inspection  of  the 
in  j 111  v.  The  writer  prefers  to  apply  plaster  splints, 
one  <)!•  more,  so  as  to  allow  of  easy  inspection  ami 
dressing  of  the  fracture;  the  whole  atVair  admitting 
of  removal  and  reap]>lication. 

Plasicr  of  Parif<  tSj)rnil.-i.  —  Having  determined 
whether  one  or  more  splints  are  required  to  support 
the  limb  without  covering  the  wound,  and  perhaps  in 
some  cases  this  may  not  be  objectionable,  suitably 
sized  pieces  of  heavy  muslin  or  Canton  flannel  are 
cut  of  a  length,  and  when  folded  thi-ee  times,  of  a 
breadth  corresponding  to  the  proportions  of  the  pro- 
posed s])lint  or  splints.  Having  sj)read  the  muslin 
(or  flannel)  out  upon  a  table,  a  thick  cream  of  plaster 
of  Paris  is  mixed  in  a  basin.  The  plaster  is  poured 
upon  the  center  part  of  the  goods,  one-eighth  to  one- 
fourth  inch  deep,  from  near  one  end  to  the  other,  and 
then  one  side  is  folded  over  the  plaster,  and  the  other 
side  over  this  side;  the  plaster  being  covered  on  one 
side  by  one  thickness  of  goods,  on  the  other  by  two 
thicknesses.  The  splint  is  ajiidied  by  gi-asping  the 
muslin  near  each  end  and  placing  it  in  the  position 
intended.  It  is  fastened  by  means  of  a  roller  bandage, 
the  upper  and  lower  ends  being  turned  down  and  up 
respectively  and  secured  with  the  l)andage.  The 
splint  soon  hardens.  One  or  several  splints  can  be 
put  on  in  this  way,  and  to  render  the  dressing  more 
firm,  one  or  two  layers  of  a  plaster  bandage  can  be 
used.  The  bandage  over  the  wound  can  be  cut.  al- 
lowing iuspectictn  and  dressing  without  interfering 
materially  with  support.  Everything  can  be  taken 
off  with  pocket-case  scissors  in  a  few  minutes.  A 
plaster  cast  without  a  window  soon  becomes  a  dirty 
affair  if  there  be  much  drainage.    It  is  a  rare  exception 


:l  y 


M 


Z     SCI 


COMI'OUiND   l'ltA(rrUUKS  Ol'   J.().\(;    I'.OMCS,  109 

I'oi*  u  CUHC  lo  do  oilier  ilinii  \\<ll  il'  (Ik-  piai-lice  rec- 
oiiuuciKlcd  is  ciiii-icd  oiil.  Tlu-  driiiiiiii^c  liibin^  Ih 
i'eiuo\('d  under  aiil  isejd  ic  irrij^;)!  ion  (bi<ddoi-i(J(; 
1-2,000)  ill  I'l-oin  six  l()  ten  days,  and  r(;paii'  jh'o- 
gresses,  but  is  delayed  somewliat.  longer  than  in  casew 
of  siiniile  fracture.  The  wound  may  not  need  dreHHing 
ofteiier  than  once  every  leii  days  oi-  I  wo  vv<'e'ks. 

77/c  Alon-  (■oinpUralal  (V^.st.v.  —  When  ex(ensi\-e  in- 
jury to  the  soft  parts  exists  the  wound  should  be  so 
opened  and  exi)lored  as  to  admit  of  thorough  antiseji- 
tic  cleansing,  suturing  of  divided  muscles  and  nerves 
witli  well  selected  sizes  of  chromic  catgut,  and  the 
placing  of  drains  so  as  to  secure  the  best  service.  It 
may  be  wise  to  fasten  the  broken  bone  ends  together 
with  silver  wire,  heavy  chromic  catgut,  or  plates  if 
there  is  great  tendency  to  displacement,  or  if  there  is 
more  than  a  little  separation  of  the  upi^er  and  lower 
ends  because  of  the  removal  of  many  fragments.  In 
this  last  case  it  may  be  wisest  to  leave  the  fragments 
rather  than  invite  non-union,  the  risk  of  necrosis 
being  less  than  non-union  if  a  thorough  antisepsis  is 
employed.  In  the  leg  or  fore-arm,  if  there  has  been 
a  destruction  of  one  of  the  bones,  the  other  not  being 
fractured,  so  as  to  leave  a  considerable  space  between 
the  ends,  it  w^ould  be  good  surgery  to  resect  or  frac- 
ture the  sound  bone  and  thus  admit  of  approximation 
of  the  widely  separated  ends  of  the  injured  bone;  the 
extremity  after  repair  would  be  shortened  but  useful. 

The  dressing  and  management  of  these  more  com- 
plicated cases  is  similar  to  that  of  less  serious  injuries 
just  described.  As  a  dressing  an  inch  or  two  thick- 
ness of  gauze  and  a  similar  thickness  of  cotton  is 
necessary  in  all  compound  fractures,  and  as  a  rule 
the  dressing  should  extend  the  length  of  the  plaster 
splint. 

Emphysema  occurs  occasionally  about  a  compound 
fracture,  or  even  extending  widely  over  a  greater  or 
less  portion  of  an  extremity.  The  condition  is  of  little 
importance  and  does  not  mean  infection  as  is  apt  to  be 
feared. 


llll  MdKlMIN    TUt:ATMENT    OF    WoiNHS. 

Jnfevtfd  Compound  Fractures. — When  compound 
fractures  have  been  treated  as  described,  they  rarely 
give  trouble  froui  int'ection,  but  should  this  follow, 
we  resort  to  frcqueut  (daily  ov  oftcuer)  irrigations  to 
flush  out  debris  aud  prevent  blocking  of  drains.  Car- 
bolic acid  in  solution  1-20  may  be  used  occasionally 
instead  of  the  birhloride  solutions,  and  even  it  may 
be  practicable  and  advantageous  to  mo])  out  certain 
places  \villi  the  pui-i'  acid,  foll<»we(l  iiunii'dialely  by 
alcohol. 

I'erfiHt  lixation  is  of  the  greatest  importance,  as 
tending  to  limit  irritation  and  prevent  spreading  of 
the  infection  up  and  down  close  to  the  bone  and  be- 
tween intermuscular  planes. 

When  sepsis  is  checked  and  repair  takes  its  place, 
union  may  progress  in  spite  of  some  necrosis  about 
the  bone.  This  necrosis  may  require  subsequent  oper- 
ation, and  occasionally  results  in  extensive  matting 
of  soft  parts  with  deformity.  Prompt  antiseptic  treat- 
ment and  pos.-^ibly  incisions  to  better  drainage  will 
limit  the  infection  to  the  soft  parts  and  repair  of  the 
bone  injury  will  go  on  undisturbed. 

Joint  Comi)Hc(itionf<. — Nowadays,  when  a  joint  is  in- 
volved in  a  compound  fraeture,  we  treat  the  joint 
injury  exactly  in  the  same  way  as  we  do  the  fracture, 
only  our  drainage  of  the  joint  should  be  complete,  i.  e., 
through  and  through,  to  prevent  accumulations  in  the 
pockets  of  the  joint  of  blood  and  exudate.  If  infection 
occurs  we  resort  to  fixation,  antiseptic  irrigation  and 
drainage,  and  usually  the  infection  can  be  controlled 
with  a  resulting  more  or  less  stiff  joint. 

Primary  resection  in  these  cases  is  sometimes  done, 
but  rarely  needed.  An  atypical  or  partial  resection 
may  be  good  practice,  as  tending  to  increase  the 
chances  of  a  useful  joint  where  displaced  fragments 
can  result  in  interference  of  motion  or.  if  loose,  be- 
come necrosed. 

Awputation. — Ami)utati(m  is  only  called  for  under 
two  conditions:  First— When  the  original  injury 
causes  a  devitalization  of  the  parts  below  the  fracture. 
The  operation  should  be  done  as  soon  as  there  is  suf- 


(X)MJ.'OUi\I)   FllAOTUItKS   01.'   LOXC    J!<JNKH.  1  1  I 

ficiciil;  i*(;ac(  ion  IVoin  shod;.  Sf.'cond — \Vli<?n  Hiipj>ij- 
ratioi),  iKMtroHiH,  and  liccMc.  H.yinplo'Dis  lia.\'c  i-oHiillcd, 
ill  H})il(!  of  lixjilioii,  drainage,  and  antinopHiH,  and  Uic 
vitality  oC  I  lie  palicnl  is  becoming  sapped.  Arapnla- 
tioii  should  bo  done  before  a  ''snceesHfiil  opeialion,*' 
hut  fatal  tei'U) illation  follow.s. 


Ill'  MmI»1:KN     IKI^AIMI^N  1     oi-    WolNDS 


CHAPTER  XVIII. 

I" ij i: A r.MK. NT  OF  (irxsiior  worxns. 

li  is  inij)ossil»lt'  lo  jiiiciiipi  iu  a  sin^U-  cliMiiicr  lo 
iiiiiii-  ihau  outiiiif  I  III'  lult's  to  be  followed  in  the  sin- 
y,iial  caiv  of  ^iiii-sliut  wounds.  The  itriiuipli's  in- 
\xdv(Hl  aiv  in  diiccl  accord  with  Ibosc  acccjiti'd  l>.\ 
modei'U  surgeons  regartlinu  ilu*  trealnu*n(  of  wounds 
in  general.  Experience  has  positively  jirovcn  that 
(///  bulh't  wounds  (with  a  tVw  excejilions  to  Ix' 
named  later)  are  nu)s(  safely  treated  by  the  antiseptic 
application  of  a  primary  occlusive  antiseptic  dressing, 
WITHOUT  preliminary,  digital,  or  instrumental  inter- 
ference or  exploralion.  The  additional  aid  of  splints 
is  called  for  in  wounds  involving  the  integrity  of  bones 
and  joints. 

When  a  bullet  has  cut  a  blood-vessel  and  hemorrhage 
is  going  on  either  externally  or  internally,  active  im- 
mediate surgical  relief  should  be  attemi)ted  by  an  ex- 
ploration sutlicieutly  free  to  a])ply  the  surgical  rule, 
viz.,  ligation  of  the  wounded  vessel  immediately  above 
and  below  the  wound.  Temporizing  measures,  such  as 
direct  comiu-ession  or  the  use  of  an  impi'ovised  tourni- 
quet, may  be  necessary  before  ligatures  can  be  used. 
The  application  of  a  ligature  to  the  proximal  end  of  a 
divided  artery  or  on  the  proximal  side  and  at  a  dis- 
tance from  the  wound  in  an  artery  is  only  justifiable 
when  the  anatomical  arrangement  or  excejitionable 
circumstances  prevent  the  a])i)]ication  of  tlie  doubl*' 
ligature. 

The  suturing  or  resection  of  arteries  and  veins 
wounded  by  bullets  has  been  ])racticed  successfully. 
but  can  scarcely  be  more  than  the  dream  of  a  military 
surgeon  in  the  field.  In  garrison  or  civil  hospital  fa- 
vorable occasions  will  now  and  then  occui-  foi-  tliis 
hith  degree  of  surgical  practice. 

VToKuds  of  the  ftlciilK  when  penetrating,  whether  or  no 
thei-e  be  symi»toms  of  compression   of  the  brain,  de- 


OUXSIIOT    VVrjI'.XDS.  IV't 

iiiiiiid  siiiT^iciil  iiilo  rciciice,  Firwl,  lii*-  scjiip  sliould 
be  whuvcd  and  llie  wound  uroji  most  carefully  pre- 
pared as  for  a  serious  operation  within  llu*  skull  (for 
example,  removal  of  a  tumor  of  Die  hrainj.  Then, 
after  turning-  hack  ;i  ''iiorseslioe  fla]»"  con(ainin{^-  the 
Avound  IJirougli  (he  scalp  somewhere  neiir  its  center, 
if  this  be  feasible,  the  opening  in  the  skull  is  enlarged 
sulficiently  to  determine  as  far  as  x>ossible  the  nature 
and  extent  of  the  injury  to  the  brain.  Through  the 
enlai'ged  skull  wound  sometimes  bone  fragments  are 
removed.  The  bullet  ought  to  be  extracted  by  follow- 
ing its  track  with  a  suitably  shaped,  dull-pointed  in- 
strument, such  as  a  closed  urethral  forceps.  Sharp- 
pointed  instruments  should  never  be  used, — in  fact, 
scarcely  any  kind  of  probe  is  safe, — because  a  false 
passage  is  apt  to  be  made.  After  locating  the  ball 
(sometimes  apparently  impossible)  it  should  be  ex- 
tracted by  means  of  a  suitable  forceps;  the  urethral 
forceps  is  scarcely  strong  enough.*  Girdner's  tele- 
phone probe  niRj  be  invaluable  in  determining  the  lo 
cation  of  a  bullet.  On  two  occasions  the  writer  has 
been  able  to  follow  the  track  of  a  ball  through  the 
l)rain  close  to  the  skull  at  a  point,  in  one  case,  nearly 
opposite  the  wound  of  entrance;  in  the  other,  at  a 
considerable  angle  below.  A  counter  opening  in  each 
case  was  made  and  the  ball  extracted.  Drainage 
should  always  be  employed,  and  when  a  counter  open- 
ing has  been  made,  should  be  of  the  ''through  and 
through"  variety,  because  the  irritation  of  the  ex- 
amination and  determining  of  the  track  of  the  ball 
might  result  in  an  inflammation,  the  outcome  of  which 
could  in  no  possible  way  prove  other  than  fatal  with- 
out drainage. 

If  a  ball  has  passed  through  the  skull,  the  wounds 
of  entrance  and  exit  had  better  be  enlarged,  all  loose 
fragments  (spicuUie)  removed  and  the  case  treated,  not 
by  ''through  and  through""  drainage,  but  by  the  local 

*  The  use  of  the  fluoroscope  and  the  taking  of  radiographs  are  valuable 
aids  in  locating  foreign  metallic  bodies  in  all  parts  of  the  anatomy.  The 
writer  succeeded  in  one  case  and  failed  in  another  to  locate  a  bullet  in 
the  brain  by  means  of  radiographs — probably  a  fair  average  of  success 
and  failure  in  similar  cases. 


114  MODERN    TREAT.MKNT    OF    NVorNHS. 

draiuajje  ol"  ciuli  woiiud,  siuli  as  om-  would  riiijtloy 
ill  any  ordinal y  (•()inj>ound  Irartm-i'  of  [hv  skull. 

(iiinahut  ivoiiikI.s  of  the  vliviit  liave  ln'cii  ri'ft'irrd  to 
ulien  disciLssing  wounds  of  the  chest,  and  nolhing  fiir- 
Ihei*  is  net'ossaiy  logaiding  lliom  at  this  time  only 
perhaps  to  emphasize  the  importauee  of  uon-interfer- 
oiice  in  all  cases  except  iliose  (lii-caHMiin^-  life  fi-oin 
lieniori-hage. 

Wounds  of  the  Abdomen. — When  a  Uall  enters  the 
abdoinoii  above  the  umbilicus  and  its  course  is  con- 
lined  above  a  plane  passed  throuj^h  and  at  right  angles 
to  the  long  axis  of  the  body  at  this  point,  non-interfer 
ence  is  justihable  under  the  following  circumstances: 

1.  The  absence  of    symptoms    denoting    hemorrhage. 

2.  If  the  bullet  is  a  small  one,  not  larger  than  a  number 
32,  especially  if  it  is  a  number  22.  :{.  If  there  is  an  ab- 
sence of  the  clinical  symptoms  pointing  to  leakage  into 
the  peritoneal  cavity  from  the  stomach  or  bowels.  1. 
The  impossibility  of  securing  suitable  surroundings 
and  skilled  sui-gical  experience. 

When  a  penetrating  or  perforating  wound  of  the 
abdomen  occurs  below  the  plane  above  indicated,  and 
it  is  possible  to  employ  clean  methods,  even  though 
the  operator  may  not  be  experienced,  but  appreciates 
the  necessity  and  can,  in  a  practical  way,  be  surgi 
cally  clean,  no  time  should  be  lost  in  opening  the  ab- 
domen, searching  for  and  repairing  all  damage  in- 
flicted by  the  bullet. 

When  a  patient  who  has  suffered  a  gun-shot  wound 
of  the  abdomen,  no  matter  where  the  wound  be  lo- 
cated, can  be  offered  all  the  essentials  of  a  modern, 
properly  conducted  abdominal  section,  no  time  should 
be  lost  after  the  receipt  of  the  injury  liefore  the  opera- 
tion is  performed. 

(hin-shot  wounds  'niroJriii!/  ho)irs  and  joints  are  of  the 
nature  of  compound  fractures.  However,  unless  the 
wound  be  inflicted  by  a  fi-agment  of  a  shell,  pellets 
from  a  shot-gun  fired  at  close  range,  or  a  very  large, 
possibly  explosive  bullet,  the  treatment  to  be  followed 
is  usually  not  that  recommended  for  compound  fra(^ 
tures.     Ordinarily,  Itullcts.  especially  those  fired  fi-om 


OUNSIIO'l'    VVOIJM^H.  115 

'iiiodeni  p'ikIoIs  and  i-ifics,  do  noi  cjiirv  f<»r('igu 
bodies  into  llic  wound.  Tin;  (rju.k  oj'  (Ik;  wound  is  ul- 
inos(:  invai'iably  froe  ffoni  gei-inH;  tliereforo,  all  dif^ital 
and  inHdumcntal  exploi-ilion  is  (o  bo  dofilorcd,  as  ex- 
perience has  proven  tliat  these  classes  of  injuries  are 
followed  by  the  least  loss  of  life  and  limb  by  the  ap 
plication,  after  antisepticisinft'  the  skin  around  about 
the  wound  of  entrance  or  entrance  and  exit,  of  a  pri- 
mary occlusive  antiseptic  dr(!M.<in^  covered  by  jjlaster 
of  Paris  or  some  other  immobilizing  splint  material. 

The  writer's  attention  was  first  called  to  the  advan- 
tages of  this  line  of  practice  by  an  article  published  in 
1883  from  the  pen  of  Dr.  Raymond,  United  States 
army,  detailing  his  experience  and  also  that  of  a 
brother  medical  officer,  a  Dr.  Ewing,  United  States 
arm3^  Together,  these  gentlemen  treated  a  number 
of  officers  and  soldiers  who  had  been  wounded  in  en- 
gagements with  Indians  in  Arizona  in  the  spring  and 
summer  of  1883.  The  results  obtained  were  as  com- 
paratively favorable  as  those  of  Reyher,  to  whom,  if 
memory  is  trustworthy.  Dr.  Raymond  referred. 

Pilcher,  in  his  recent  work,  quotes  Reyher  and  says : 
■'Out  of  28  cases  of  gun-shot  wounds  of  the  knee,  with 
bullet  imbedded  in  the  parts,  the  4  which  were  treated 
in  accordance  with  these  principles,  from  the  onset, 
recovered  with  movable  joints;  8,  in  which  antiseptic 
precautions  were  not  adopted  until  the  next  day,  died, 
as  well  as  4  which  had  no  such  treatment  at  all ;  while 
of  the  remaining  12  which  had  no  primary  antiseptic 
treatment  and  required  either  intermediate  or  second- 
ary amputation,  11  died.  Of  46  cases  of  wounds  of  dif- 
ferent joints  treated  as  above,  6  died — mortality  13 
per  cent.;  of  these  19  required  primary  resection,  of 
which  only  2  died — 10.5  per  cent.  Of  78  cases,  similar 
in  other  respects,  but  in  which  antisepsis  was  a  sec- 
ondary consideration,  or  from  which  bullets  had  been 
extracted,  48  died — 61.5  per  cent.  Of  another  series 
of  62  shot  wounds  of  joints  without  primary  precau- 
tions, 39  died — 63  per  cent.  So  in  cases  of  shot  frac- 
ture of  long  bones,  of  65  treated  from  the  first,  only  5 
died — 7.6  per  cent.    Of  29  not  so  treated.  8  died — 27 


116  .\iiii>i:i:.\    rKKAT.MKNi'  ttr  whlm'S. 

jtcr  (fill,  in  ;i  nciulihorin^  lu)S}(ilal  ti)  his  own  diiriuj; 
I  lie  <;iiiiii;rmii  ill  I  lie  ('aucjisus  Iit*yli(.'r  saw  7  cases  of 
uiifoiiijilicaii'tl  wounds  of  soft  parts  die  of  i)_vt'niia; 
under  his  own  i)riniary  antiseptie  measures,  he  hist 
one  such.  In  another  series  of  G5  fractures  treated 
secondarily  by  antiseptic  rules,  23  died — 35.3  per  cent. 
As  illustratiu";  the  reduced  number  of  cases  of  pye- 
mia, altofjether  of  nI  <ases  of  miscellaneous  wounds 
treated  primarily,  only  5  died  from  blood  poison — 6.1 
per  cent;  whereas,  of  143  not  so  treated,  46  died — 32.1 
per  cent.  Of  Tu  various  wounds  of  the  skull,  l)uttocks, 
and  soft  parts,  all  treated  antisejitically  from  the 
start,  not  one  died.  Out  of  the  46  cases  of  guu-shoi 
wounds  of  joints  it  was  only  necessary  in  4  cases  to 
depart  from  the  system  of  primary  occlusion  without 
interference;  whereas,  of  75  cases  of  similar  wounds 
treated  by  secondary  antisepsis,  drainage,  etc..  in  54 
of  them  resections  or  amputations  were  required." 

The  results  obtained  in  the  treatment  of  our 
wounded  in  the  recent  war  with  Si)ain  prove  that  Rey- 
her's  suggestion  and  practice  may  be  expected  to  be 
followed  by  the  best  results  in  all  classes  of  gun-shot 
wounds.  Lacerated  gunshot  wounds  should  be 
treated  by  the  most  ]>ainstaking  digital  and  instru 
mental  exi)loration  and  interference,  such  as  has  been 
suggested  in  the  treatment  of  compound  fractures  ex- 
tensive in  character.  These  are  the  kind  of  wounds 
in  which  clothing  is  apt  to  be  carried  into  the  tissues, 
fascia  extensively  lacerated  and  thus  conduits  opened 
for  extensive  infection.  When  a  gun  shot  wound  has 
become  infected,  drainage  and  antiseptic  irrigation 
should  be  the  rule.  Amputation  should  only  be  re- 
sorted to  when  the  vitality  of  an  extremity  has  been 
distroyed  or  infection  demands  removal.  Never  probe 
a  bullet  wound  unless  the  presence  of  the  bullet  in  the 
tissues  is  giving  rise  to  symptoms  justifying  its  re- 
moval. 

Since  reading  the  paper  of  Dr.  Raymond  (some  of 
whose  wounded  were  personal  friends  or  old  patients), 
in  1883,  immediately  after  its  publication,  the  writer 
has  invariably  followed  Reyher's  practice.     All  kinds 


GUNSHOT    WOINDS.  11.7 

of  wouikIh  li.'ivc^  l)('(*ii  iiicL  Willi  uiul  I  lie  rcHiills  \\avi- 
almost  hi\ aiiably  hccn  i'jivoi-ahic  vvlicii  (Ik*  iiatiiri'  ol 
the  wound  did  not  of  ilscir  roi*  iIh-  nicliiod  ol  ilH 
virtue. 

TREATMENT    OF   (iUN-SHOT    WOUNDS   Ol'     Till';    K'IDNKV    AND 

LIVKH. 

Among  a  numbcn-  ol'  (-uses  of  wounds  examined  by 
an  American  Hurge'on  visiting  in  Athens  two  (victims 
of  the  Gra3co-Turkis]i  war)  of  successful  termination 
of  gun-shot  wounds  of  the  liver  without  operation 
were  observed.  Heveral  like  results  are  reported  by 
American  Surgeons  at  Santiago.  These  results  bring 
forcibly  to  mind  three  fatal  cases  in  the  writer's  prac- 
tice. 

The  causes  of  death  from  gun-shot  wounds  of  the 
liver,  when  non-complicated,  are  shock  and  hemor- 
rhage, the  usual  mortality  being  about  85  per  cent. 
When  from  the  direction  of  the  course  taken  by  the 
bullet  the  indications  are  that  a  wound  of  the  lower 
free  border  of  the  liver  has  occurred,  resort  should 
be  had  to  abdominal  section,  the  injury  to  the  liver 
repaired,  when  practicable,  by  suture,  and  the  ab- 
domen closed  without  drainage.  When  the  nature 
of  the  injury  demands,  in  addition  to  suture,  resort  to 
tamponade,  drainage,  of  course,  must  be  established. 
If  other  viscera  are  involved  the  usual  surgical  prac- 
tice in  such  cases  should  be  followed.  All  other  non- 
complicated gun-shot  wounds  of  the  liver  should  be 
treated  by  elevation  of  the  foot  of  the  bed,  absolute 
rest,  and  the  hypodermic  administration  of  morphine. 
Ergotal,  turpentine,  and  gallic  acid  may  possibly  be 
given  with  advantage,  but  strychnia  hypodermically 
is  impei'ative.  Another  important  point  is  the  fixa- 
tion of  the  right  side  of  the  chest  and  abdomen  by 
adhesive  strips  put  on  over  the  primary  occlusive 
dressing.  The  adhesive  plaster  should  be  arranged 
s'o  as  to  form  a  splint  encircling  the  right  half  of  the 
chest  and  abdomen  from  just  under  the  axillary  folds 
to  a  point  one  or  two  inches  below  the  anterior  su- 
perior iliac  spine. 


118  MOI>i;iJ.\     ritKAT.MKNT    Vl'    WolNDS. 

The  objfct  (»r  (rciitnu'nt  in  these  casey  is  to  coinbal 
shoek  aud  lavor  the  eessatioii  ol"  hemorrhage.  The 
entrance  of  blood  and  bile  into  the  peritoneal  cavity 
is  of  itself  comparatively  free  from  danger,  and  in  the 
ca^^es  upon  which  the  writer  has  operated,  although 
there  was  a  considerable  (luantity  of  clotted  and  free 
blood  in  the  abdomen,  especially  the  right  hypochon- 
driac regi(»n.  the  active  hemorrhagi'  at  the  time  of 
operation  was  not  alarming,  but  became  so  and  con- 
tinued after  the  removal  of  the  clots  and  the  intro- 
duction of  the  gauze  tamponade.  This  has  so  im- 
pressed itself  upon  me  that  I  will  hardly  feel  justified 
to  again  resort  to  such  a  procedure  unless  there  is 
plausible  evidence  of  injury  of  other  viscera  besides 
the  liver. 

When  there  is  a  complicating  wound  of  the  kidney, 
the  o])ei'ator  should  content  himself  with  a  retro-peri- 
toneal incision,  by  which  the  wounded  kidney  may  be 
explored  and  drainage  established.  If,  however,  this 
incision  should  disclose  that  probably  from  the  na- 
ture and  position  of  the  wound  in  the  kidney  (and  the 
patient's  generol  condition)  that  a  rapid  intra-abdom- 
inal hemorrhage  was  taking  place  from  the  kidney, 
resort  should  be  had  to  an  immediate  nephrectomy 
through  a  retro-peritoneal  incision  and  free  drainage 
provided.  The  leakage  of  a  smaller  or  greater  amount 
of  urine  into  the  peritoneal  cavity  from  a  wounded 
kidney,  otherwise  a  healthy  organ,  is  of  small  moment, 
and  in  both  illustrations  of  complicating  Iddney 
wounds  is  best  managed  by  gauze  drainage  through 
retro-peritoneal  incisions. 

Uncomplicated  gun-shot  (also  stab)  wounds  of  the 
kidney  should  be  managed  exactly  as  just  recom- 
mended. There  may  be  exceptionable  instances  when 
the  trans-peritoneal  route  may  be  preferable,  but  even 
in  case  this  may  be  chosen,  an  incision  should  be  made 
in  the  loin  for  the  purposes  of  drainage. 

A  suggestion  as  to  the  method  of  controlling  rapid 
hemorrhage    from    the    liver    following    a     gun-shot 
wound  not  accessible  to  suture  may  be  worth  men 
tinning.     The  wound  of  entrance  should  be  exposed, 


GUNSHOT  WOUNDS.  119 

resort  being  had  Lo  resection  ol"  one  or  moic  ;il>s  il 
neeewsury,  und  tlu'oug']i  tlie  track  of  tlie  wound  jkihh 
a  bougie  or  catlieter,  by  which  means  a  gauze  tampon 
or  a  non-])(!rl'orated  i-ubbei-  lulling  may  be  drawn  so 
as  to  compresw  the  whole  li'a(;k  of  the  wound,  and 
thus  control  the  bleeding.  It  i«  only  in  a  case  of  what 
promises  to  be  fatal  from  hemorrhage  that  this  or 
any  other  operative  pi'Of-edui'e  except  as  indicated 
above  is  justifiable. 

In  my  first  case  t'liere  was  a  complicating  wound 
of  the  kidney.  Treatment  was  by  abdominal  section, 
removal  of  clots,  gauze  tamponade  and  drainage 
through  an  incision  in  tlie  loin.  The  patient  suc- 
cumbed from  tlie  continuance  of  the  hemorrhage. 

Second  case.  The  wound  was  confined  to  the  li\er. 
Treatment  was  by  abdominal  section,  removal  of  clots, 
gauze  tamponade  and  drainage.  Death  from  hem- 
orrhage. 

Third  case.  Complicating  wound  of  the  kidney. 
Treatment  was  by  retroperitoneal  incision  and  drain- 
age of  the  kidney;  abdominal  section,  removal  of 
clots,  gauze  tamponade  and  drainage.  Death  from 
continuance  of  hemorrhage. 

In  the  first  and  last  cases  the  hemorrhage  from  the 
kidney  itself  was  trifling.  The  abdominal  incision  in 
all  eases  was  at  the  outer  side  of  the  right  rectus 
muscle.  I  feel  positive  that  the  change  for  the  worse, 
in  each  of  these  cases,  immediately  follo"wing  opera- 
tion, was  so  marked  that  the  intra-abdominal  opera- 
tion was  a  mistake. 

Stab  wounds  of  the  liver  which  may  or  may  not  be 
perforating,  according  to  the  nature  of  the  instrument 
and  the  position  of  the  wound  (usually,  however,  not 
perforating),  are  perhaps  best  treated  by  abdominal 
section  and  suture.  A  few  cases,  notably  one  oper- 
ated upon  by  Dalton,  of  St.  Louis,  would  indicate  that 
this  is  the  correct  line  of  practice. 

The  position  taken  regarding  the  non-operative 
treatment  of  certain  gun-shot  wounds  of  the  liver 
may  not  be  in  touch  with  the  advanced  ideas  of  the 
skirmishers  on  our  line  of  surgical  progress,  but  much 

9 


ILMI  MODKltN    TllKATMKN'r    OK    WOINUS. 

is  bfiii^  h'iiriUMi  bv  Aiiicritaii  surji(*<»iis,  as  a  ri'sult  of 
•nir  war  with  Sjtain,  rcjiardin^  tlu'  siibjccl  ()f  gun- 
shot wounds,  and  this  acquired  knowledge  will  re- 
sult in  a  higher  conservatism;  a  bi*lter  aitpreoiation 
of  the  j)owers  of  nature.  There  are  limitations  for 
good.  Theiv  are  boundaries  too  oflon  overstepjx'd  in 
our  zeal  to  prove  the  "harmlessuess  of  a  surgical 
operation  aseptically  performed."' 

The  writer  siiggesttnl,  when  discussing  gun-shot 
wounds  of  the  abdomen,  that  "When  a  patient  who 
has  suftered  a  gun-shot  wound  of  abdomen,  no  matter 
whore  the  wound  is  located,  can  be  surrounded 
bv  all  the  essentials  of  a  modei-n,  ]n-oj)erl.v  conducted 
abdominal  .section,  no  time  should  be  lost  after  the 
receipt  of  the  injury  before  the  operation  is  per- 
formed." This  ought  to  be  qualified  and  i"ead,  ''ex- 
cept when  the  wound  is  of  the  liver  and  uncom])li- 
cated,  or  probably  so,"  then  the  suggestions  just  made 
ought  to  receive  due  consideration. 


I'.TJIINH   AND    IltoST  I'.ITIOS. 


(JHAPTER  XIX. 

TREATMENT  OF  BURNS  AND  FROST-BITES. 

Burns  vary  so  iiincli,  both  locally  and  const iiu- 
tionally,  according  to  (lie  causo,  duration  of  tin;  action 
of  the  cause,  locality  and  area  ol"  the  action  of  the 
cause,  that  it  would  seem  well  to  briefly  consider  these 
points. 

Uncovered  parts  of  the  face,  body,  and  extremities 
(especially  among  those  unaccustomed  to  outdoor  life), 
when  exposed,  during  hot  weather,  for  some  hours  to 
the  rays  of  the  sun,  suffer  burns,  usually  quite  super- 
ficial in  character.  Explosions  of  gases  are  apt  to 
produce  large  burns.  Burning  or  superheated  solids 
and  liquids  cause,  in  the  former,  deep  burns;  in  the 
latter,  extensive  burns.  Of  the  former,  metals,  phos- 
phorus, sulphur,  and  resinous  substances;  of  the  lat- 
ter, oils  and  viscid  solutions  are  the  most  common 
agents.  Ohemicals  also  cause  inflammation,  and  in 
some  cases  destruction  of  the  tissue  in  much  the  same 
way  as  hot  or  burning  solids  and  liquids. 

The  fire  of  ordinary  combustible  materials, — in  fact, 
all  causes  of  burns  are  dependent  in  their  effects  upon 
the  length  of  time  they  act  on  the  tissues  and  the  ex- 
tent of  the  surfaces  involved,  varying  from  a  simple 
reddening  of  a  small  area  of  skin  or  mucous  membrane 
to  a  complete  cooking  or  destruction  of  a  smaller  or 
greater  part  of  the  body. 

Besides  the  direct  effect  of  burns  upon  the  external 
body,  numerous  internal  congestions  and  inflamma- 
tions may  follow  as  complications.  Among  the  early 
complications  we  sometimes  observe  congestions  of 
the  pharyngeal  and  laryngeal  mucous  membranes, 
usually  resulting  from  inhalations  of  hot  air  or  steam. 
These  may  be  called  primary  complications.  Later, 
complications  are  seen  in  congestions  of  the  brain, 
lungs,  and  intestinal  tract.  The  congestion  of  the  up- 
per part  of  the  intestine  sometimes  ends  in  the  forma- 
tion of  an  ulcer,  the  well-known  duodenal  ulceration 
'w  hich.  in  rare  instances,  perforates. 


ILL  MiinKKN   rKKA'r.\ii:N'r  oi'  wiunks. 

The*  lali'  coiiijilic;!!  ions  arc  iisiiallv  sc*i»lic'  in  rliai- 
acter  and  aiv  sonieiinu's  uianit't'sied  by  iiiliaiiuualions 
of  (he  nu'iiin^cs  of  llu'  brain,  (ho  ph'ura.  (he  liin<;.s, 
and  tho  jtoritoni'iiin.  ( 'icai  licial  cDniraci  inns  arcom- 
pauyinji'  (ho  repair  of  a  buni,  whole  iheie  has  beeu 
jfioator  or  less  destruction  of  tissue,  oftentimes  re- 
sults in  (h'l'orniily  and  less  of  runciion  of  llie  parts 
involved. 

Formerly  it  was  cusiomary  to  divide  burns  into  six 
defjrrees.  but  a  sinijiler  classification  is  better  and  more 
coiiiiiiehensible.  In  jtractice  we  have  to  meet  with 
those  burns  in  which  (here  is:  il.i  Hyperemia  (red- 
ness) and  swelling;.  Either  no  vesicles  are  formed 
and  repair  takes  place  by  exfoliation  of  the  epider- 
mis and  iti-i  replacement  without  su])pnration,— there 
is  no  scar, — or  vesicles  form  tilled  wi(li  serum.  The 
surfaces  beneath  tlie  vesicles  may  or  nuiy  not  suppu- 
rate. Repair  takes  place  with  some  little  discolora- 
tion of  the  skin,  but  there  is  usually  \r\-y  lit  He  scar 
tissue  formed.  (-.)  More  or  less  inllamed  areas,  with 
Aesications  covering  varying  degrees  of  depth  of  skin 
reached  by  the  causative  agent.  Sometimes  the  epi- 
dermis is  destroyed  and  peels  off  easily,  leaving  a 
juicy,  grayish  surface  beneath.  Sometimes  the  tis- 
sues are  dry,  yellowish,  or  almost  black.  Both  rep- 
resent lifeless  tissues.  In  such  cases  the  depth  of  de- 
struction depends  upon  the  duration  of  the  action  of 
the  cause.  When  due  to  direct  action  of  fire,  parts 
may  become  completely  charred.  Repair  of  burns  of 
these  seA'ere  kinds  takes  place  by  granulation. 
Sloughs  form  in  the  moderately  severe  and  bad  bni-iis 
l^'illeroyj. 

In  order  to  formulate  a  line  of  trealmen(  we  may 
adopt  a  classification  dividing  burns  into  four  degrees, 
viz.:  (1.)  Burns  in  which  there  is  reddening,  erythema 
or  hyperemia.  (2.)  Burns  in  which  there  is  a  forma- 
tion of  vesicles  or  blebs,  but  which  do  not  involve  the 
(utis  or  true  skin.  {'.">.)  Burns  in  which  the  entire 
dei)th  of  the  skin  is  destroyed.  (4.1  Burns  in  which 
there  is  the  formation  of  sloughs  or  in  which  there  is 
'liai-i-ini;-. 


T.UItNH   AND   KROH'r-l'.rriOS.  ]-S., 

Siiiil>iiiiis  will  be  iiK'iil  i(»iH'(i  liisl,  l>('<;iiis<i  I  hey  u,r(; 
iisviiilly  of  (lie  IctiHi.  H(;v('i'il.y  unci  yield  lo  Ircalinent, 
or  gel.  well  without  treutnieut,  in  ;i  short  tinio.  The? 
bui'UH  are  superficial  in  character, — a  simple  erythema 
or  reddening-  of  the  Hldn, — but  are  of  I  en  quite  ])ainful. 
Buruf^  of  lliis  (•haracter  and  oth(M-  sliglit  or  moderate 
burns  may  be  ti'cated  with  a  solulion  of  soda  bicar- 
bonate or  by  covering  the  surface  burned  with  some 
bland  substance  like  carbolized  vaseline,  bismuth  sub- 
nitrate,  white  lead  and  oil  as  used  by  jtainters.  In 
an  emergency  Hour  may  be  thickly  sprinkled  over  the 
entire  burned  surface.* 

Burns  of  all  other  degrees,  in  which  the  tissues  be- 
neath the  cuticle  are  exposed,  are  wounds,  and  as 
such  must  be  treated.  AVhenever  it  is  possible  these 
burns  should  be  treated  antiseptically  from  the  first. 
Burns  are  suspicious  wounds  always,  and  if  antiseptic 
treatment  is  not  begun  at  once  infection  and  i>us  are 
always  sure  to  follow. 

Burns  of  the  second  degree  are  attended  by  the  for- 
mation of  blebs  and  vesicles,  which  are  raised  above 
the  surrounding  skin,  and  where  the  blebs  are  rup- 
tured the  true  skin  is  exposed. 

In  the  treatment  of  this  class  of  burns  the  skin 
around  the  burn  should  be  thoroughly  scrubbed  with 
soap,  followed  by  alcohol  and  bichloride  1-1,000. 
Then  with  the  thumb  forceps  and  scissors  all  loose 
cuticle  and  all  cuticle  covering  the  blebs  should  be 
removed,  after  which  the  whole  burn  should  be  irri- 
gated with  1-5,000  bichloride  or  1-100  carbolic.  If  the 
surface  is  a  large  one  and  the  pain  is  severe,  this,  as 
well  as  the  completion  of  the  dressing,  may  be  done 
under  an  anesthetic. 

Now  as  to  the  dressing.  It  must  be  remembered 
that  whatever  dressing  is  used  it  must  be  non-irritat- 
ing, and  must  be  such  that  its  removal  will  not  disturb 
the  wound.  One  of  the  best  dressings  is  perforated 
oiled  silk  or  gutta  percha  tissue  applied  directly  to  the 
burned  surface.     The  perforations  must  be  more  than 

*  A  saturated  sohitiou  of  picric  acid  iu  water  is  a  grt^teful  application 
in  all  kinds  of  mild  bnrus.  Orthoform  in  powder  or  mixed  with  sterile 
vaseline  J  dr.  to  1  oz.  is  anesthetic  and  antiseptic. 


li'i  .MohKUN   rui;Ai'.Mi:Ni  oi'  wor.Nns. 

nuTt'  sliis;  iln-v  iinisi  lie  lai'j;v  iMioiijili  lo  allow  I'itc 
esfiiiH'  of  siMiim  and  I'Xiulalr.  Over  this  is  idacinl 
enough  moist  stiM-ilizcd  jiaii/c  lo  absorb  llu'  cxiulatc, 
ami  ilu'ii  altsorbt'iil  cotton  covered  with  lyarallint'  pa- 
per ami  a  bandage  Another  splendid  dressing  is 
earbolized  vasi'line  spread  iij)on  sterilized  surgeon's 
lint.  This  form  of  dressing  is  always  very  grateful 
to  the  patient.  In  sovere  burns  of  the  third  or  fourth 
degree,  in  whirli  iIkmc  is  a  tendency  to  exulxM-ani 
granulation,  the  oiled  silk  or  rubber  tissue  is  i»erha[ts 
the  better  of  the  two  mentioned,  as  it  tends  to  keep 
down  granulations.  These  two  forms  of  dressings 
ha\  e  at  least  two  advantages  over  the  dry  dressings  or 
dusting  powders:  First,  there  are  never  dried  hard 
ciusts  of  secretion  next  to  the  burn;  second,  the  dress- 
ing is  easily  removed  and  does  not  have  to  be  softened 
with  water  "peroxide,"  etc.,  before  its  removal  is  pos- 
sible. 

The  dressings  should  no!  be  removed  before  four  or 
five  days,  unless  the  odor  of  decomposition  is  noticed. 
^A'here  the  surface  burned  is  too  large  or  it  is  not  pos- 
sible to  follow  out  the  antiseptic  treatment  given 
above,  or  when  the  patient  is  in  a  state  of  extreme 
shock,  either  from  the  burn  or  from  other  injuries,  it 
is  then  not  advisable  to  spend  much  time  trying  to 
appl^'  an  antiseptic  dressing. 

In  those  cases  where  the  life  of  the  patient  depends 
upon  as  (luick  relief  as  jtossible,  one  of  the  best  things 
at  our  dis})osal  is  absorbent  cotton  saturated  with 
equal  parts  linseed  oil  and  lime  water.*  This  excludes 
the  air,  can  be  applied  cpiickly,  and  thus  reduces  the 
danger  from  shock,  the  i)atient  being  almost  at  once 
jiut  to  bed  and  active  restorative  measures  begun 
without  delay.  AA'here  it  is  possible  in  these  extreme 
cases  it  is  best  to  give  an  anesthetic,  which  reduces 
shock  and  gives  a  better  opportunity  to  dress  the  case 
properly;  but  the  contra-indicalions  to  an  anesthetic 
must  be  duly  considered. 

*Tlic  use  (if  linseed  oil  and  lime  water  ("carron  oil  ").  flour,  etc.,  is 
not  in  line  with  modern  snrgii-il  tlicraiieutics  and  should  be  allowed  only 
in  the  e)ner?;i-ncies  of  great  sliock  or  when  better  dressings  cannot  be 
secured. 


lUJUNH   AN]>   KUOHT-JWTKH.  125 

VV^haL  Jias  been  siiid  of  lli<-  liisi  <licssiii^  in  bnniH 
of  the  Becoiid  device  will  also  apply  lo  hiii-iiH  of  iIk- 
third  dogree,  bui-n.s  in  wliicii  not  only  tiie  cuticle?  hiii 
the  cutis  has  beeu  destroyed,  lliat  is,  the  entire  skin 
is  destroyed  wiih  or  wiliioiil  I  lie  t'oi'nialioii  of 
sloughs;  but  the  after-treatment  may  vary  considera- 
bly. In  burns  of  I  lie  second  degree  epidermization 
takes  place  wilhonl  the  formation  of  scars,  leaving 
only  a  slight  r(Mlness  or  discoloration,  while  in  burns 
of  the  third  degree,  healing  takers  ])lace  vvitli  mor(i  oi- 
less  scar  formation  and  later  cicatricial  contraction. 

In  these  burns  several  factors  may  delay  very  con- 
siderably the  recovery.  First — The  burn  may  be  and 
quite  often  does  become  infected.  Second — The 
formation  of  extensive  sloughs  from  deep  burns,  and 
the  consequent  long  time  for  the  throwing  off  of  the 
slough  and  the  filling  up  of  its  area  with  granulation 
tissue.  Third — ^Exuberant  granulations,  which  are 
soft  and  flabby  and  are  raised  above  the  edges  of  the 
surrounding  skin,  preventing  epidermization.  Fourth 
— ^The  surface  burned  may  be  so  large  that  the  skin 
around  it  cannot  grow  over  it,  or  else  it  does  so  very 
slowly. 

Infected  burns  must  be  treated  antiseptically  and 
usually  require  dressing  once  a  day.  The  pus  should 
be  disintegrated  with  a  solution  of  peroxide  of  hydro- 
gen, and  the  wound  irrigated  with  1-1,000  bichloride  or 
other  antiseptic  solution.  Care  should  be  taken  so 
that  as  little  bleeding  as  possible  is  caused  either  by 
sponging  or  attempting  to  remove  sloughs,  as  these 
bleeding  points  send  the  infection  still  deeper.  In 
these  cases  Morris  uses  equal  parts  of  fluid  extract 
of  ergot  and  warm  water,  squeezed  from  a  sponge,  and 
allowed  to  flow  over  the  surface  infected,  and  claims 
that  profuse  suppuration  is  sometimes  cut  short  by 
one  such  application;  giving  as  a  reason  that  the  er- 
got produces  a  local  stimulation  of  the  vasomotor 
nerve  filaments,  causing  a  condition  of  high  tension  in 
the  blood-vessels,  thus  inhibiting  the  trausmigraTion 
of  leucocytes,  etc.  In  the  second  condition  it  is  often 
necessary  to  stimulate  the  formation  of  sranulation.s. 


1_(»  Mc>L>i:ii.\    lUKATMENT  «>F   WolNDS. 

aiiil  lor  iliis  i»iir[i()sc  siciTai*-  of  /iiir,  taloiiu'l.  clc. 
may  be  im-niitnu'il.  Kxiibi'iaiit  j;raiuilaiit>ns  siu-li  as 
(sjK)k('ii  ol"  iiiusi  he  kept  down,  'i'liis  i«  very  cll'ei'liiully 
iloiu-  Willi  solid  sil\(  T  nil  rale  or  I'lse  by  snippinj;  ilu-ni 
(iir  Willi  sharp  scissors;  liic  roiiiu-r  usually  ^Incs  iln- 
bt'tlcr  results. 

Skin  jjrai'tiug  plays  a  \ciy  ini|ioriaiii  jian  in  ihe 
treiitinvul  of  burns  ol"  ibe  iliird  and  lourih  degrees 
and  should  be  resorted  to  more  often  than  it  is.  First 
— Burns  of  large  areas  may  be  made  to  rei)aii*  in  one 
oi-  two  weeks  which  otherwise  would  reiniire  months. 
i^econd — Cicatricial  contraction  may  be  hugely  pre- 
vented. Third — The  repair  of  sii]>i)uraling  burns  is 
very  much  hastened  l)y  grafting.  Tlu?  Thiersch 
method  should  be  used,  drafting  should  begin  just 
as  soon  as  the  granulating  surface  is  tirm,  that  is, 
when  there  are  no  flabby  granulations.  It  is  not  nec- 
essary to  wait  until  you  have  a  wound  free  from  pus, 
for  I  have  repeatedly  done  skin  grafting  with  perfect 
success  where  much  pus  was  present.  On  the  con- 
trary, skin  grafting  always  cuts  short  suppuration; 
nor  is  it  necessary  to  curette  the  surface  before  graft- 
ing, as  some  claim.  Of  course  the  wound  should  be 
made  as  clean  as  possible.  A  very  excellent  dressing 
is  sodium  chloride  and  calomel,  in  the  itroportion  of 
one  of  the  former  to  fotir  of  the  latter.  'J'liis  to  l)e  a])- 
}>lied  on  the  day  before  the  grafting  is  done. 

Before  grafting,  the  burn  shouhl  be  thoroughly  irri- 
gated with  strong  bichloride,  followed  by  boracic  acid 
solution.  All  bleeding  points  should  be  controlled  by 
jiressure.  Tlie  grafts  sliould  be  a}»plied  to  the  granu- 
lation surface  wliich  has  been  sponged  dry.  as  they  ad- 
here much  better  to  a  dry  surface.  The  dressing  is 
the  rubber  tissue,  oiled  silk,  or  else  sterilized  or 
borated  vaseline.  The  dressing  should  not  be  re- 
moved for  at  least  four  days,  unless  conditions  of  suj)- 
I»uration  or  something  else  should  absolutely  demand 
it.  When  the  grafting  has  been  done  under  aseptic 
conditions  the  dressing  may  remain  much  longer. 

<lreat  care  should  be  used  always  that  the  grafts 
are   not  disturbed   when    dressings  are  changed.     If 


I'l.AlK     l\. 


Extensive  Imrii  uiuUv  proL-oss  of  veintir  liy  Thii-i-scirs  method 
of  skin-u'iMftiug.  (Fi-ora  a  patit'iu  in  the  Clurkson  Hos- 
pital. ) 


I'.UIINS   AND   lltOS'L'-J'.lTES.  127 

only  a  iKii-l  of  Uk'  i^iJilliiiK  'im  l><'  <l<""'  <"  *"""  ^'"lii'J^, 
it  in  bessL  lo  place  a  i-ovv  of  tliciii  aioiiiid  Ww.  edges  oi 
the  wouud  at  a  little  diHlaiice  li-oin  I  lie  Hkiii  lino. 
•Then  in  a  few  days  another  set  may  Im;  placed  iiisidi- 
the  first  one. 

In  burns  of  (lie  exlreiiiit  ies  of  I  lie  iliii'd  or  luuiili 
degree,  vvliere  a,  portion  of  Hk;  exireniily  lias  been 
either  cooked  or  charred,  amputation  is  the  only  re- 
source, and  is  to  be  done  as  soon  as  the  patient's  con- 
dition will  permit. 

The  general  treatment  for  the  shock  is  the  same  as 
for  shock  from  any  other  condition  and  has  been  dis- 
cussed in  another  chapter.  As  mentioned  above,  cica- 
tricial conlractions  may  be  to  a  great  extent  prevented 
by  skin  grafting.  The  complications  must  be  treated 
as  they  are  met.  It  must  be  remembered  that  kidney 
complications  are  almost  certain  to  follow  burns  of  ex- 
tensive areas,  and  in  these  cases  the  complications 
should  be  anticipated  as  far  as  possible  by  proper 
prophylactic  treatment. 

In  burns  over  large  areas,  even  though  the  patient 
may  feel  pretty  well,  and  the  burn  does  not  seem  se- 
vere, the  prognosis  should  always  be  carefully 
guarded. 

A  duodenal  ulcer,  which  has  perforated,  would  be 
indicated  by  well-recognized  symptoms  of  intestinal 
perforation.  An  immediate  operation  for  the  closure 
of  the  perforation  gives  the  patient  the  only  chance 
for  life. 

Burns  caused  by  chemicals  should  be  treated  by  the 
immediate  application  (by  swallowing  in  case  of  the 
l>harynx  and  esophagus)  to  the  surface  involved  of  a 
chemical  having  an  opposite  reaction,  and  at  the  same 
time  being  non-irritating  in  itself.  Burns  caused  by 
strong  acids  should  be  treated  by  the  application  of 
an  alkaline  substance,  such  as  bicarbonate  of  soda  or 
lime  water.  These  will  neutralize  the  excess  of  the 
acid.  Vinegar  or  any  dilute  non-irritating  acid  may 
be  used  in  case  of  burns  by  strong  alkalies.  Milk  and 
the  white  of  eggs  should  be  given  after  the  swallow- 
ing of  either  strong  alkaline  or  acid  chemicals.     Whis- 


1_^  MODEUN  TltKATMKNT  OF  WOINHS. 

kcv  (H-  hraiulv  must  hv  adiiiiuisteivd  after  I  Ik-  atri- 
(Iciiial  taking  of  c-arbolic  atid.  Alcoliol  sd  chaiigi's 
tlu'  clu'inical  action  of  carbolir  acid  as  i(»  render  it 
praciically  inert  in  its  elVecl  upon  ihe  tissues.  The 
stoniacli  may  be  washed  out  witli  e(|ual  ]>ai'ts  of  whis- 
key and  walef  or  a  iTt  pel-  cenl.  soluiiou  of  alt oliol  in 
watei".  Ii  preNcnts  lis  absofpiion  as  carbolic  acid. 
and  even  mi^lil  ad  as  an  anli(h)ie  lo  carbolic  acid 
poisoning;  if  y:iveu  in  large  doses — one  initial  dose  of 
two  to  four  ounces.  This  may  be  repeated  as  often  as 
indicated.  The  idea  being  to  surcharge  the  system 
with  alcohol,  short  of  danger  froui  the  alcohol  itself. 
Surface  burns  from  chemicals  retjuire  the  same  treat- 
ment as  other  burns. 

TREATMENT  OK  FROST-BITE. 

Frost-bites  of  exposed  parts,  as  tlie  ears,  nose, 
cheeks,  and  lingers,  need  little  or  no  arienlion  unless 
the  exposure  has  been  of  some  considerable  duration. 
Under  such  circumstances  the  re-establishment  of  ac- 
tive circulation  in  the  pale,  benumbed  tissues  is  first 
brt)Ught  about  by  frictions  with  a  warm  hand.  As 
soon  as  it  is  observed  that  the  circulation  is  return- 
ing, the  parts  may  be  rubbed  with  snow  or  bathed  in 
cold  water.  The  object  in  using  snow  or  cold  water 
being  to  overcome  as  far  as  possible  too  great  dilata- 
tion of  the  blood-vessels  in  the  frost-bitten  parts  after 
the  return  of  the  blood  into  their  paralysed  walls;  also 
the  return  of  the  blood  is  gradually  brought  about.  It 
is  this  local  overdistention  of  the  blood-vessels  which 
permits  of  the  clinical  symptoms  of  inriammation. 
In  fact  it  is  practically  impossible  to  prevent  some 
redness  and  swelling  with  subsequent  desquamation, 
but  the  continued  local  ap])lication  of  moist  cold  will 
tend  to  reduce  inliammaiion  and  its  conse(jueiices. 
An  ointment  of  ichthyol  and  lanoline,  one  part  in 
eight,  is  beneficial  in  the  early  desquamative  stage. 
The  lead  and  ojuum  wash  is  also  useful. 

Severe  frost-hite,  threatening  the  vitality  of  the  dis- 
tal  parts  of  an   extremity,  is  a   very   serious  alTair. 


BUUNS  AND   I'-ltOSr-JJITES.  129 

:I1  is  tlic  i-('Siill;iiii  nillaiiiiniil  ion  lollowiii;:,  lin-  rctiii-ii 
of  I  lie  riiculiitioii  in  pjirtH  not  ubHoiiilcly  i<ill(Ml  by 
cold  Hull  (mkIh  in  Iohh  of  lil'o  to  (he  tisHuoH, — gangrene. 
Stimulation  and  well  rcH-ogrii/cd  nidliods  for  the  res- 
toration of  the  weakened  circnlalion  are  esHential. 
So  soon  as  any  existing  dang<'rous  gen(M-al  deiiression 
is  relieved  and  the  heart  tone  restored,  tlien  the  frost- 
bitten parts  should  be  thawed  out  by  using  cold 
water  and  frictions. 

Even  in  the  homes  of  the  very  ])Oor  cold  water 
may  be  made  to  drip  upon  the  extremity  from  a  sus- 
pended bucket,  using  most  any  material  for  the  cap- 
illary drain.  The  patient's  bed  can  be  kept  dry  by  a 
suitably  arranged  rubber  sheet  or  table  cover  oil- 
cloth, the  waste  water  draining  into  a  vessel  i)laced 
upon  the  floor  by  the  side  of  the  bed.  This  method 
of  keeping  up  the  continued  use  of  wet  cold  is  quite 
as  effective  as  any  of  the  more  elegant  means  em- 
ployed in  hospital  practice.  The  cold  water  should  be 
used  until  the  inflammatory  symptoms  subside  or 
until  by  the  formation  of  a  line  of  demarcation  nature 
points  out  where  life  ceases  and  death  begins.  Any 
antiseptic  can  be  dissolved  in  the  cold  w^ater,  perhaps 
bichloride  of  mercury  1.5,000  is  the  best  for  general 
use.  After  the  line  of  demarcation  is  formed  hot  fo- 
mentations or  thot  antiseptic  poultices  are  useful  to 
hasten  the  separation  of  the  dead  from  the  living 
parts. 

When  gangrene  has  developed,  but  it  is  uncertain 
to  what  place  it  will  extend,  the  writer  likes  to  use 
Labarraque\s  solution  in  the  cold  water,  of  the 
strength  of  one  or  two  ounces  to  the  gallon.  This 
solution  is  both  antiseptic  and  deodorant.  Except  in 
gangrene  of  a  whole  hand  or  foot  no  typical  amputa- 
tion should  be  done.  Dead  fingers  and  toes  are  best 
removed  by  dividing  the  bones  with  forceps  and  al- 
lowing the  ends  to  granulate.  Judicious  skin  grafting 
may  do  away  with  amputations  of  major  parts  of  the 
hands  and  feet,  likewise  this  practice  will  shorten 
convalescence.  When  an  amputation  of  a  smaller  or 
greater  part  of  a  foot  is  required  the  whole  mechau- 


i;{0  MiiliKKN    lUKATMK.NT   OF   WOUNDS. 

isiii.  SO  lar  as  iis  l>oii_v  tranie  is  coucerued,  shoiiUl  be 
trealod  as  one  l>oiu'.  No  attempt  at  fashioninji  llaps 
after  the  uiclhods  of  tlu'  textbooks  should  bo  inado. 
The  bones  slioiild  1m-  divided  just  above  the  i)oiiils 
wliei-e  tliev  are  uiipiotefled  bv  the  grauulaliug  soft 
jiaiis.  r.v  i-aiiisiaking  care  of  the  grauuhitiug  sur- 
faees  and  the  use  of  Thiersch's  Haps  <;ood  sei'vicabk.' 
stuiiii)S  cau  be  secured  with  the  sa»  rilice  of  the  small- 
est amount  of  tissue. 

The  impressions  of  an  earlv  experience  in  lu.v  pio 
fessional  career  may  be  related  with  prolii.  hi  ilic 
winter  of  1881-1*,  while  the  writer  was  connected  with 
1h(^  arm.v,  two  soldiers  whose  feet  were  badly  frost- 
bitten were  brought  to  the  post  hospital.  These  men 
were  members  of  a  hunting  party.  The  felt  boots 
which  they  wore  had  become  wet  during  the  day 
while  walking  through  the  melting  snow.  In  the 
excitement  of  killing  and  butchering  a  buffalo  just 
before  dark  they  were  ignorant  of  the  changing  tem- 
perature and  the  freezing  of  their  feet  and  legs  until 
camp  was  reached.  Foolishly  the  frozen  parts  were 
first  thawed  out  by  the  fire,  they  were  then  wrapped 
in  blankets  and  the  men  sent  to  the  hospital,  where 
they  arrived  a  few  hours  later.  On  admission  the  feet 
were  swollen  and  of  a  ripe  black-cherry  color,  the 
legs  to  the  upper  parts  of  the  middle  thirds  were 
of  a  dark  red  color.  Numerous  bulhe  had  formed  con- 
taining a  prune  juice  colored  serum.  Wet  antiseptic 
dressings  were  applied,  over  which  cotton  was 
wrapped.  During  the  first  twenty-four  hours  it 
looked  as  if  nothing  would  stop  the  threatening  gan- 
grene and  that  the  result  would  be  a  loss  for  both 
men  of  their  feet  with  the  lower  thirds  of  their  legs. 
Cold  water  dressings  were  then  begun,  and  a  change 
for  the  better  was  soon  noticeable.  The  cases  re- 
sulted in  each  man  having  one  foot  removed  at  the 
medio-tarsal  joint  and  the  other  about  one  and  one- 
fourth  inches  below  this  line.  Numerous  opportunities 
for  observing  similar  or  even  worse  cases  have  since 
fallen  to  my  lot,  and  in  many  instances  I  have  been 
able  to  saAe,  by  the  continued  use  of  wet  cold,  parts 


lUJUNS    AND    FUOST-I'.rriOH.  131 

tlial  by  any  oUkh-  (r<'u(iii(;ril  would  have  surely  been 
Hacri/iccd.  IC  cxd'ciniMcH  wlii<-li  liav<i  b(;(?n  H(;vc*roly 
frost- bitLeii,  but  wliose  vilality  Ih  not  abHolutoly  do- 
stroyed,  are  seen  within  a  reanonable  time  after  the 
exposure,  there  oiighi  not,  as  a  rule,  to  be  a  f^va'dtar 
loss  to  the  suri"(;rer  than  jiarts  of  one  or  several 
phalanges. 


132  MODKUN  THEATMENT  OE  WOUNDS. 


r  11  AFTER  XX. 

rsE  oi"  i;i  iu'.i:k  (.aintlets  ok  i. loves. 

Xuiiu'ious  wavs  ot  washing  the  bands  by  surgeons, 
assistants,  and  nurses  bave  been  recommended.  Some 
of  Ibcsc  iiu'ihods.  if  done  intelligently  and  conscien- 
liously.  art'  suj»]>(>st'dly  ivliablc  otlicrs  are  less  relia- 
ble. Wben  not  safeguarded  all  are  objectionable,  be- 
cause they  have  to  include  in  their  canyiug  out  the 
personal  equation  of  the  individual.  11  ihe  most  ex- 
perienced, worthy,  and  reliable  may  lorgei  at  the  criti- 
cal moment,  when  of  all  others  he  should  remember,^ 
what  must  be  expected  of  the  one  recognized  by  the 
courts,  the  one  of  ordinary  skill  and  intelligence! 

Greater  still  than  the  dangers  of  infecting  wounds 
by  the  surgeon,  who  uses  ordinary  diligence  and  skill, 
is  the  danger  of  infecting  women  after  childbirth  or 
abortion  by  the  attending  physician  and  nurse.  The 
nature  of  the  general  practitionei's  calling;  treating 
all  kinds  of  disease;  coming  and  going  at  all  hours; 
occasionally,  because  of  necessity  or  preference,  doing 
''chores"  about  the  barn,  house,  and  office, — all  this 
leads  to  a  weaning  away  from  the  practice  of  ideal 
surgical  cleanliness  on  his  part,  both  as  physician  and 
surgeon.  Besides  it  takes  daily  painstaking  practice 
to  successfully  learn  how  to  be  surgically  clean. 

Let  it  be  granted,  for  the  sake  of  argument,  that  a 
])hysician  in  attendance  upon  the  general  run  of  cases, 
such  as  pneumonitis,  pleuritis,  typhoid  fever,  diar- 
rhea, headache,  indigt^stion,  constipation,  and  such 
like  ailments,  is  practically  free  from  the  danger  of 
conveying  these  ailments  to  other  patients,  (.'an  the 
same  be  said  of  all  forms  of  ulceration,  abscess, 
phlegmonous  inflammations,  erysipelas,  tetanus,  puer- 
]>eral  s(>j)sis,  diptheria,  scarlet  fever,  etc.? 

i  know  that  no  physician  would  willingly  cause 
unnecessary  suffering  and  danger  to  those  who  have 
given  him  their  confidence  and  ]ilaced  theii"  health  and 


IJSIO   OF   IIUIUUOR   (JAtJN'I'MO'rS   Olt   (U.OViOH.  !•*■> 

lives  iiJ  liis  kccidiij^,  ;in(l  il  in  in  (his  spirii  lluii  I  wv^^a 
11i(!  liJibilnal  use  of  Hlcrili/^cd  fiiblxT  ^Iovck  or  <;;miit 
lets,  after  cleaiiHirig'  the  liaiidH  l).y  some  j4oo(l  iiiclliDi), 
in  every  case  where  one's  intelligence  points  out  the 
advaiila^c  lo  (lie  i>a(i('ii(.  //  sJioiild  he  the  nih:  (1)  in 
obs<e(ric  i)ractice;  (2j  in  o[>('ra,ling  upon  all  forms  of 
septic  cases;  (3)  in  the  examination  and  treatment  of 
all  forms  of  septic,  infectious  diseases,  such  as  ery- 
sipelas, seplicemia,  and  pyemia,  in  which  the  hands 
conie  in  con  (act  with  ])rimary  and  secondary  foci  of 
infection — and  this  rule  applies  to  the  nurse  also;  (4) 
in  operating  upon  cleoAi  cases  soon  after  operations 
done  upon  infected  ones;  (S)  in  the  examination  of 
fresh  wounds  after  recent  examinations  of,  or  opera- 
tions upon,  dirty  cases;  (G)  in  abdominal  sections  fol- 
lowing vaginal  operations  upon  the  same  individual 
— this  may  be  reversed,  wearing  the  gloves  during  the 
vaginal  work,  taking  the  gloves  off  or  donning  a  fresh 
pair  before  beginning  the  abdominal  work;  (7)  in  all 
forms  of  rectal  surgery. 

It  is  a  matter  of  choice  under  other  circumstances 
whether  or  no  gloves  be  worn.  However,  there  is  no 
(luestion  but  that  there  is  less  danger  of  infection 
where  gloves  are  worn  than  when  reliance  is  x>la<:'ed 
in  an  attempted  sterilization  of  the  naked  hands. 

An  impervious  cotton  glove  is  perhaps  quite  as  good 
as  the  rubber  article.  The  ordinary  cotton  glove  is 
not  safe.  During  the  time  I  have  been  using  rubber 
gauntlets  in  my  work  I  know  that  my  results  have 
been  more  gratifying  than  formerly.  My  work  has 
covered  a  very  broad  field.  The  cavities  of  the  skull, 
spinal  canal,  thorax,  and  abdomen  have  been  invaded, 
besides  many  operations  of  election  and  emergency 
upon  the  neck,  trunk,  and  extremities  have  been  done, 
a  sufficient  experience  to  base  an  opinion  upon,  and 
my  cases  have  been  freer  from  all  kinds  of  infection 
than  ever  before.  Ever}-  surgeon  who  is  in  the  habit 
of  doing  a  great  amount  of  surgical  work,  if  honest, 
will  confess  that  suppuration  occasionally  occurs  in 
his  practice  where  least  expected;  it  has  done  so  in 


i;i4  mohkun    tickat-Mknt  t»i'  woinus. 

mint',  ir  I  lie  wcni-ini;  of  sicrih'  ruhhcr  ^Mtncs  will 
lessen  ihe  ilanj:»'r  of  infei-iion,  we  sluuihl  wear  theui. 
Oteasionally  1  lunc  fell  conipelled  lo  lake  oil"  the 
•jlovos  in  order  lo  <  ariv  (Hil  soiuv'  terhnique  more  sat- 
isfactorily, but  siicli  ails  seldom  occur  now.  There  is 
liiile  dilVerence  in  ladile  seiisibilily  iieiween  the 
naked  linj^^-rs  and  those  covered  with  a  well  lil  led, 
iiood-articled  rubber  glove.  The  advantaj^cs  oul  weigh 
the  possible,  in  rare  instances,  lessened  tactile  aeute- 
ness.  One  dozen  ]»airs  of  the  best  (jualitv  can  be 
bought  for  ^lo.  Sterilized  glycerine  may  be  used  lo 
lubricate  the  hands  before  drawing  on  the  gloves. 
A  glove  that  cannot  be  reasonably  easy  drawn  over 
the  hand  after  tilling  the  glove  with  sterile  water  is 
too  small.  "N'aseliue  or  grease  ruins  Ihe  rubber.  The 
gloves  should  be  either  boiled  or  wrapju'd  in  a  lowid 
and  jtlaced  in  a  steam  sterilizer.  Lastly,  rubber 
gloves  are  a  ])rolection  to  the  ydi.vsician  and  sui'geon 
against    infection. 


Il^DEX. 


Abdomen,  incise.d  nnd   pniicl  m-cd   wounds  of,  40. 
wihere  to  open,  40. 
penetrating-  wounds  of,  41,  42,  41). 
stab  wounds  of,  41. 
flusliing  and  draijiing-  of,  44. 
falls,  kicks,  and  blows  upon.  45. 
I^assage  of  wagons,  etc.,  over,  4  5. 
contusion  of,  48. 
gunshot  wounds  of,  114,  120. 
Abdominal,  intra,  lesions,  ti'eatment  of,  51. 
intra,  hemorrhag-e  and  shock,  45. 
intra,  hemorrhage,  fatal,  48. 
section,  21  41,  44,  52,  53,  119,  V.',?,. 
wall,  non-penetrating  w^ound  of,  treatment,  40. 
surgery  upon  battle-field,  42. 

viscera,  lapai'otomy  for  gunshot  wounds  of,  43. 
walls,  contusions  of,  45. 
Abscess,  compound  inflamiuatorj'  gravitation,  49. 
in  infected  joint  injuries,  60. 
intracranial,  65, 
superficial,  100. 
Accidental  wounds,  treatment  of,  26. 

materials  for  disinfection  and  dressing  of,  26. 
location  of,  26. 
kinds  of,  27. 
hemorrhag'e  in,  28. 
shock  in,  29. 
punctured.  31. 
of  4th  of  July,  31. 
of  hands  and  feet,  31. 
proper  treatment  of,  32. 
Adhesions,  fibrinous,  56. 

Adhesive  plaster,  use  of,  in  approximating  edges  of  granulat- 
ing wounds,  23. 
use  of,  over  antiseptic  gauze  in  accidental  wounds.  26. 
as  a,  primary  dressing  in  sprains,  57. 
as    splint    over    primary    occlusive    dressing    in    gunshot 

w^ounds  of  the  liver,  117. 
bandage,  26,  23. 
Air  aspirated  into  chest,  37. 

Alcohol,  use  as  disinfectant,  24,  26,  62,  69,  72.  106. 
use  of,  in  preparing  catgut,  6.  7,  9. 
use  of,  in  treatment  of  shock.  28. 
xise  of,  as  a  stimulant,  25.  63. 
use  of,  in  preparation  for  operation,  106. 
use  of,  after  accidental  burns  with  carbolic  acid.  128. 
effect  of,  upon  nervous  centers,  102. 
10  (135^ 


i;u;  INDEX. 

Aiiiputalion,  iiulicalions  for,  30,  :>9.  110. 
demaiul  of,  30. 
shoi'k  hefori',  30. 
when  to  })erforni,  30,  63.  IIG. 
in  civil  practice,  02. 
how  to  perform,  63. 
in  erysipehis,  86. 
Amputation,  treatment  after,  63. 
in  jiunshot  wounds  of  knee,  11.j. 
in  case  of  .'^evere  frost-bite,  130. 
in  case  of  cooked  or  cliarred  cxliemity,  1:2;. 
Anesthetics,  consideration  of  gfiving  of,  124. 

choice  of,  OS. 
Ankk>  joint,  32. 
Antiseptic  surgery,  3,  84,  100. 
gauzes,  10. 
solutiooi,  24,  85,  129. 

dressings.  24,  25,  28,  38,  62,  72,  73,  86.  101.   1U4.  112. 
digital  examination,  29. 
treatment,  39,  62,  74,  110. 
incisions,  58. 
irrigation,  62,  66,  8,).  110. 

technique,  in  compound  fractures  of  long  bones,  105. 
precautions,  in  operating,  107. 
poultices,  129. 
Antistreptococcus     seriim,     emploj'mcnt     of.     in     acute     and 

chronic  infections,  63. 
Arm,  effect  of  septic  lymphangitis  upon,  73. 

condition  of,  resulting  from  snake  bite,  76. 
Arnold  sterilizer,  10. 
Artery,  intercostal,  38. 

internal  mammary,  38. 
Aseptic  surgery,  what  is  understood  by,  3. 
sterilization  of  hands  in,  3. 
wounds,  59.  17  (supposedly), 
behavior  of,  17. 
temperature  during,  18. 
dressings  of,  18. 
use  of  iodofoi'm  in,  19,  20. 
treatment  of  infection  of,  19. 
stitches,  their  extraction  after.  20. 
Aspiration  of  intra-articular  blood  and  synovial  fluid  accamu 

lations,  58. 
Assistants,  wearing  of  rubber  gloves  by,  132,  133. 
washing  of  hands  by,  132. 

Bacteria,  1,  87,  88. 

effect  of,  on  wound  healing,  1. 

shape  and  size  of,  1. 

di\-isions  of.  1. 

location  and  origin  of,  1,  2, 

required  tempera tiire  for  growth  of.  2. 

effect  of  heat  and  chemicals  upon,  3. 
Bandage,  9,  13. 

adhesive  plaster,  23,  26. 


IN  DION.  l-iT 

I'iciiioi-iiic,  swi  III  ion  oi',  f),  i:i,  r.i. 

:i1cIm)Ii()I,  7. 
of  nici-ciiry,  7,  H. 
("ther,  9. 

wet  clressiiig,  19. 
Bites,  of  insc(!ts,  74. 

syiu|)tonis  result  i  ii^'  rroiii  iii.-ecl   stiiif^.s  ;i  inl   l)ii<rs,  74. 

tj'caiiiu'iit  oJ',  75. 

o:f  spidei'  species,  75. 

of  serpents,  75. 

effect  ot,  75. 

symptoms  of,  75. 

treatment  of,  77. 
of  animals,  of  liiinian  bein{>s,  79. 

treatment  ol',  79. 

Bladder,  rnptui'e  of,  49. 

character  of,  49. 

history  of  accident  of,  49.  : 

proof  of,  50. 

intra-peritoneal,  50. 

extra-peritoneal,  50. 

combined  treatment  of  intra-  and  extra-peritoneal,  5:!,  54. 

nse  of  Harris  instrument,  Kelley  cystoscope  and  uretei'al 
catheter  in  determining  source  of  hematuria,  47,  48. 
Bleeding,  cheeking  of,  in  accidental  wounds,  28. 

continuance  of,  result,  38. 

tying   of   mesenteric   vessels    to   control    intra-abdominal 
hemornhage,  48,  53. 

bleeding  of  post-mortem  examination  wounds,  74. 
Blood,  amount  of,  in  arteries  during  shock.  29. 

vessels,  action  of  digitalis  upon,  29. 

supply,  destruction  of,  result,  30. 

flowing,  antagonistic  to  germ  growtli.  31. 

accumulation  of,  in  pleural  cavity,  37. 

overdistention  of  pericardium  Avith,  38. 

evacuation  of,  from  pleural  cavity,  38. 

vessels,  matei-ial  for  tying  of,  44. 

in  urine,  47. 

synovial  fluid  mixed  with,  55. 

effused,  incisions  for  evacuation  of,  in  contusions,  5S. 

supply,  65. 

coagulation  of,  76, 

extravasation  and  exudation  of,  ti6. 

poisoning,  septic,  93. 
treatment  of,  93. 
Boeckmann  sterilizer,  10. 
Bone,  frontal,  33,  34,  35. 

compound  fractures  of  long,  103. 

treatment  of  shock  accompanying,  103. 

use  of  antiseptics  on  protruding,  105. 

simple  case  of  injury  of,  107. 

use  of  plaster  of  Paris  splints  in  case  of  Injured.  lOS. 

destruction  of.  in  leg  or  forearm,  109. 
treatment  of,  109. 


138  INUKX. 

Brain,  pum-luied  wounds  of,  31,  33. 

locality  of  injuries  of,  33. 

tissue,  33. 

treatment  of  injuries  of,  33,  34. 

symptoms.  G7,  08. 

injury  to,  duriny  liirtli,  07. 

contusion  of,  07,  OS. 

compression  of,  OS. 

penetration  of,  OS. 

eare  of.  duriny  operation,  OS. 

injury  to,  by  {gunshot  wounds,  113. 

meninges  of,  inflammations  of,  122. 
Bruises,  treatment  of,  27. 
Bullets,  chest  wounds  caused  by,  30. 

lung  injuries  caused  by,  30. 

indications  of  force,  size,  and  directions  of,  37. 

wounds  caused  by,  in  abdomen,  41,  114. 

location  of,  bj-  means  of  fiuoroscDpe  and  radiograph.-:,  113. 

treatment  of  all  wounds  caused  bj',  114,  ll.j. 

lacerated  wounds  caused  by,  110. 

wounds  of  liver  and  kidney  caused  by,  117,  IIS,  119. 

treatment  of  wounds  caused  by,  118,  119,  120. 
Burns,  variation  of,  121. 

area  and  locality  of,  121. 

by  gases,  solids,  liquids,  and  chemicals.  121,  127.  128. 

effect  of,  upon  external  body,  121. 

primary  complications  of,  121. 

later  complications  of,  122. 

classification  of.  122. 

of  sun,  12!!. 

of  second  degree,  123. 

treatment  of,  123,  124,  125. 

infection  of,  125. 

skin  grafting  in  treatment  of,  120. 

general  treatment  for  shock  caused  by,  127. 

Carbolic  acid,  use  of.  in  disinfecting.  5,  20. 

use  of.  in  chromicizing  kangarc  o  tendon.  S. 

as  an  antiseptic  solution,  10,  11.  17. 

as  antiseptic  irrigating  fluid,  1-!. 

power  of,  as  a  chemical.  14,  l.">. 

power  of,  as  an  antiseiJtic,  I'J. 

poisoning  and  burning,  use  of  alcohol  in,  1;.'7,  12S. 
Carbonate  of  soda,  5,  10. 
Carron  oil  in  treatment  of  burns.  124. 
Catgut,  sterilization  of.  0,  7. 

as  prepared  by  supply  houses,  7. 
Catheters,  51,  119.' 

u.se  of.  in  rupture  of  bladder,  44. 
in  diagnosis  of.  50. 

Kellev's  ureteral,  use  of,  47. 
Cellulitis,"  diffuse,  24. 
Cheese  cloth,  preparation  for  use,  9. 
Chest,  penetrating  wounds  of,  30. 

treatment  of  penetrating  wounds  of,  38. 

gunshot  wounds  of,  114. 


INDEX.  l->-J 

Chloride  of  calciiini,  5. 

of  ]iiri(',  5. 
Chlorororm,  (18,  \)2. 
Cold  applications,  80. 

ap|)lic!i1ion  of  ice  to  chest,  38. 

packiiig,  63. 

water,  128,  129,  I.'IO. 
Compound  wounds  of  joints,  49. 

fractures  of  sknll,  07. 
treatment  of,  07. 

fractures  of  long  bones,   103. 
Compressions  of  brain,  08,  112. 
Concussio])  of  brain,  07. 
Contusions  of  scalp,  60.  , 

simple,  37. 

of  abdominal  walls,  45,  49. 

of  joints,  55,  58. 

of  brain,  67. 
Corrosive,  sublimate,  power  of,  14. 
Cupping,  79. 

Degrees  of  burns,  122. 

treatment  of,  123,  124,  125,  126. 
Delirium,  peculiarities  of,  in  pyemia,  98. 

in  erysipelas,  83. 

nocturnal,  in  pyemia,  97. 
Diagnosis  of  tetanus,  91. 

of  penetrating  wounds  of  chest,  36. 

dilTerential,  between  wounds  of  pericardium  and  iieart,  37. 
Diaphoresis,  a  feature  of  tetanus,  90. 
Diarrhea  in  septic  blood  poisoning,  93. 

in  pyemia,  developed  after  compound  wounds  of  joints,  01. 
Digitalis,  use  of,  in  shock,  29. 

tincture  of,  28. 

properties  of,  29. 

action  of,  29. 
Di-aiuage,  17,  20,  29,  66,  68. 

provision  for,  in  antiseptic  surgery,  4,  34. 

tubes,  11. 

free,  22,  65,  85.  « 

open,  for  disinfection,  24. 

fenestrated  rubber  tubing,  use  of.  for.  24. 

"through  aaid  through,"  25. 

of  brain,  34. 

in  rupture  of  kidney,  53. 

in  peritonitis,  rupture  of  bladder,  54. 
Dressing's,  14,  17. 

stei-ile,  3. 

dry  sterile,  9. 

moist  antiseptic,  9,  26. 

of  non-suppurating  wounds,   17. 

in  accidental  wounds,  19,  20. 

in  operations  on  infected  tissues,  22,  23. 

antiseptic,  non-irritating,  23. 

medicated,  23. 

antise]3tic,  30. 


1  iu  iM>i:x. 

Drugs,  till'  adiiiiiiistratioii  of,  28. 

Dura,  ()J<. 

JJyspnfii  ill  woiimls  of  perii-anliuin  and  hiari.  :;?. 

Edema,  !S:i. 

causing  vosii-k's  ai\il  builte  in  i-rj'sipelas,  82. 
Kinac'iatioji  in  pyemia.  ('>i.   U)li. 
Eiuphysema  iu  compound  fractures,  JOU. 

iu  wouuds  of  ehest,  37. 

in  retro-peritoneal  rupture  of  intestiue,  49. 

in  extra-peritoneal  rupture  of  bladder,  51). 
Empyema,  saeeulated.  of  lower  pleural  cavity,  '.)'.». 
Ei)it.helioma,     dilVerentiation     of,     from     "Dissecting     porter's 

wart,"  72. 
Ergot  in  hemorrhage  from  rupture  of  the  spleen  and  liver.  51. 
Ergotal  in  gunshot  wounds  of  the  liver,  117. 
Erysipelas,  definition  of,  80. 

bodies  deail  from,  70. 

discovery  of  germ,  SO. 

contagiousness  of,  81. 

symptoms  of,  82, 

of  scalp  and  face.  s:.'.  s::. 

phlegmonous.  S:!. 

gangrene  in,  84. 

isolation  of  cases  of,  iu  hospitals,  84. 

use  of  sterilized   rubber  gloves  in,  84. 

treatment  for  cutaneous,  85. 

cellulo-cutaneoiis,  85. 

dressings  in,  SC. 

skin  grafting  after.  86. 
Esmareh  tourniquet,  G'J. 

"first-aid  i)ackages,"  105. 
Ether,  Squibb's.  10. 
Extraction   of  stitches,   20. 
E.xtra-peritoneal  rupture  of  the  bladder,  50,  54. 

result,  51. 
E.xtravasation  of  blood,  27,  66. 

of  urine,  24,  45. 

Face,  erysipelas  of,  82. 

wounds  of,  closed  with  care.  10. 
Feet,  puncture  wounds  of,  .'!1. 

frost-bitten,  i:U). 
Fever,  high,  in  infected  wounds  of  hands  and   feet.  32. 

continued,  in  infected  wounds  of  joints.  (;2. 

in  tetanus,  90. 
Forceps,  dressing,  18. 

control  of  hemorrhage  by.  15. 

use  of,  in  extraction  of  an  interrupted  slitcli.  20. 

thumb.  123. 
Forearms,  lower,  72. 

disinfection  of,  by  physicians  and  assistants  before  oper- 
ations, 72. 
Foreign  body  in  punctured  wouiul  of  brain,  33.  34. 

in  gunshot  wounds,  115. 


INDBxV.  1  i  1 

Fractures,  conipoiind,  oj:  loiif4'  bones,   lO:!,  lot,  105. 

extimjivaiioii  and   Ireaiment  of,  lOr). 

wae  of  pkiHter  of  Paris  splints  in,  108. 

more  eon i plicated  eases  of,   lO'.i. 

emphysenui  al)OMl  eonipoiind.   101). 

infected  compound,   110. 

eompotind,  of  skid  I,  G7. 

treatment  of,  07,  OS,  fii). 
J'^rost-bite,  treafment  of,  \2S. 

severe,  1^8. 

gangrene  in,  12!). 

treatment  of,  129. 

Gangrene,  development  of,  in  erysipelas,  8.1,  84. 

clevelo])ment  of,  in  frost-l)ite.  129. 
treatment  of,  129. 

iji  snake  bites,  77. 
Gauze,  nse  in  wounds  for  diainage.  9,  24. 

iodoform,  pad,  16. 

preparation  of,  10. 

sterilization  of,  10. 

use  of,  for  sponging  wounds,  11. 
Genitals,  external,  insect  bites  of,  75. 
Gland  or  glands,  removal  of,  in  wounds  of  spleen,  44. 

suppurating,  74. 

incision  and  treatment  of.  74. 
Grafting,  skin,  after  burns,  126,  127. 

after  erysipelas,  86. 
Granulation,  exuberant,  in  burns,  124.  125. 

tissue,  122. 

conversion  of  matrix  into.  7.3. 
Gunshot  wounds,  112. 

of  abdomen.  40.   114. 

of  the  skull,  112.  113. 

of  brain,  113. 

of  chest,  114. 

of  liver  and  kidney,  117. 

causes  of  death  from,  117. 

treatment  of.  117,  118. 

uncomplicated,  of  kidney,  118. 

involving  bones  and  joints,  114. 

laparotomy  for,  of  abdominal  viscera,  43. 
Gut,  silkworm,  sterilization  of,  6. 

catgut,  sterilization  of,  6. 

as  sold  and  prepared  by  supply  houses.  7. 
ligation  with,  15. 
Gutta  percha  tissue.  123. 

Hands,  punctured  wounds  of,  31. 

disinfection  of.  before  operation.  5. 

of    tlie    anesthetizer.    in    treatment    of    fractures    of    the 
skiill,  68. 

iiifected  wounds  of.  caused  by  bite.  79. 
Head,  tetanns.  90. 

injuries.  64. 


142  1M)KX. 

ileart.  woiimls  of,  ;!G,  37,  o'.i. 

stimulants,  in  insect  bites,  74. 

beat,  after  serjient  bites,  ~j. 
Hectie  fever,  03. 
Hematuria,  use  of   Kelley  i-vstosi-ope  and   ureteral  dilator-s  in 

determining  source  of,  47,  48. 

life-threatening,  53. 
Hemorrhage,  symptoms  of,  37. 

internal,  in  rupture  of  spleeu  and  liver,  15. 

rapid  intra-])eritoneal,  52. 

caused  by  rupture  of  kidney,  o2. 

cause  of  swelling,  in  contusions  of  joints,  5S. 

in  incised  wounds  of  head,  04. 
treatment  of,  04. 
Hernia,  of  the  lung,  30,  39. 

radical  cure  of,  use  of  kangaroo  tendon  in,  S. 

supporters  to  prevent  formation  of,  aftei   abdominal  sec- 
tion, 21. 

reduction  of,  3'J. 

Incised  wounds,  26. 

wounds,  complicated,  location  of,  20,  27. 
wounds  of  special  parts,  27, 

treatment  of,  27. 
wounds  of  abdomen,  40,  42. 
scalp  wounds,  04. 

treatment  of,  04. 
Incision  or  incisions — 

through    apparently    ihealthy    tissues    to    reach    infected 

tissues,  22. 
made  to  I'elieve  tension,  22,  25. 
made  for  evacuation  of  fluids,  22. 
wound  irrigation  after,  23. 
suitable,  free  drainage  established  by,  24. 
in  4th  of  Juh-  wounds,  31. 
free,  for  inflammation,  32. 
direction  of,  32. 

for  evacuation  of  blood  from  pleural  cavity,  3-<. 
in  empyema,  39. 
in  the  loin,  47. 
median,  54. 

extensive,  to  check  pyemia,  03. 
made  through  scalp,  69. 
multiple,  in  limb  after  snake  bite,  78,  79. 
Infection,  prevention  of,  32. 

in  wounds  of  mediastinum,  30. 
of  compoimd  joint  injuries,  60. 
absence  of,  temperature  in,  60. 

Injury,  injuries — 

concealed,  catised  by  punctured   wounds,  31. 

of  eye,  33. 

location  of,  to  brain,  33. 

treatment  of,  to  brain,  33,  34. 

complicated,  35. 

of  joints,  60. 


INIHOX. 

JiiduiniiialiDii,  IS,  ;.'(),  22,  20. 

siipcrficiul,   IH. 

m;\\i(:  (■ii-c'iiiusci'ihcd,  2^!,  24. 

ill t'cctioiis,  2'l. 

Kiij)j^)iir;ilivc  cellular,  24. 

incisions  to  prevcjii  spread  oJ!  celhiliir,  25. 

in  contused  and  lacerated  wounds,  30. 

secondary,  in  ])iin<;1ia'ed  wounds,  31. 

treatment  of.  in  wounds  of  i'eet,  etc.,  32. 

secondary,  in  orl>it,  35. 

seoondai-y,  in  pericardia]  wounds,  38. 

in  compound  vvoiiiuls  of  Joints,  59. 

in  infected  joint  injuries,  GO,  61. 

the  result  oi"  post-mortem  infection,  72. 

after  insect  strings  or  bites,  75. 

difFuse  cellular,  in  serpent  bites,  77. 

in  erysipelas,  80,  83. 

cellulo-cutaneoiis,  treatment  of,  101. 

result  of  examination  of  track  of  bullet  in  skull,  113. 
Insect  stings  and  bites,  74. 

treatment  of,  74,  75. 
Instruments,  sterilization  of.  10. 

care  of,  10. 
Intestine,  intestines — 

opening  into,  injury-  by  puncture,  31. 

protrusion  of,  in  wounds  of  abdomen,  40. 

gunshot  and  stab  wounds  of,  43. 

wounds  of,  best  material  for  closing.  44. 

small,  rupture  of,  49. 

retro-peritoneal,  rupture  of,  49. 
indications  of,  49. 
Iodine,  tincture  of,  79. 

as  a  disinfectant,  26. 

iise  of,  in  snake  bites,  79. 
Iodoform,  11. 

gauze,  preparation  of,  10. 

powder,  10,  19. 

gauze,  22,  25. 
packing,  23. 

property  of,  95. 
Irrigation,  irrigations — 

of  fresh  wounds,  14. 

antiseptic,  in  treatment  of  joint  injuries,  62,  109. 
in  erysipelas,  85,  86. 

copious,  in  septicemia,  94. 

in  infected  compound  fractures,  110. 

antiseptic,  in  joint  complications,  110. 

of  burns,  126. 

Jaw,  muscles  of,  involved  in  tetanus,  87. 

effect  of  tetanus  upon,  89. 
Joints,  complicated  inc'sed  w^ouuds  near.  26.  27. 

sprains  and  contusions  of,  55,  56. 

classification  of  Avounds  of,  55. 

result  of  injuries  of,  56. 

treatment  of  injuries  of,  56.  57. 

compound  wounds  of,  59. 


143 


144  iNi>i:x. 

Joints — voinlinltd. 

cleanliness  of  ilressiuifs  in,  59. 
wounds  of,  of  np])or  extremities,  ;')<). 

■   results  of,  5'.t,  GO. 
infeeteii  eoiupouiul  injuries  of,  GO,  Gl. 

all  kinds  of,  60. 
treatment  of  punctured  wounds  of,  G2. 
coniplieations  of.  in  compound  fractures.  110. 
jjunshot   Nvounds  involviu}^'  bones  and,  114,  115. 

Kangaroo  teniloii.  ()reparatit)u  of.  use  of,  8. 
Kidney,  rupture  of,  45. 

cases  in  point,  45,  46,  47. 

nse  of  Harris  instrument   and   Kelly  cystoscope  and   ure- 
teral dilators  in,  47,  4S. 
intra-i)eritoneal  hemorrhage  from,  5:.'. 
retro-jjeritoneal.  •">-. 

treatment  of.  5~.  5.'!. 
development  of  sepsis  following.  5',. 
life-threatening  hematuria,  result  of  injury  to,  53. 
rupture  of.  accumulating  hemorrhage  in  pelvis  following, 

53. 
complicating  gunshot  wound  of,  IIS. 
uncomplicated  gunshot  wounds  of,  118.  Hit. 
Kitasato,  tetanus  bacillus,  87. 
Krug  frame,  12. 

Lacerated  wounds,  siriousness  of,  27. 
shock,  resulting  from,  27. 
examination  of,  ."37,  28. 
contused  and,  27. 

careful  antiseptic  digital  exaniinat  ion  of,  2it. 
of  abdomen.  40. 
inflicted  by  teeth,  79. 
Laparotomy,  for  gunshot  wounds  of  abdnmiiial  viscera,  43. 
for  gunshot  and  stab  wounds  of  intestines.  43. 

mortality  from,  43. 
benefit  of,  in  battles,  44. 
Leiter  coil,  62. 
Lesions,  intra-abdominal,  45. 
Ligatures,  sterilization  of,  C^. 

use  of.  in  jjyemia.  102. 
Line  of  demarcation  in  frost-bites.  129. 
Liver,  rupture  of.  45. 
wounds  of.  44. 

treatment  of,  44. 
gunshot  wounds  of,  117. 

canses  of  death  from,  when  non-complicated,  117. 
treatment  of,  117, 
Lock  jaw.    See  Tetanus. 
Lung,  hernia,  36,  39. 

treatment  of,  39. 
wounds  of,  36. 
dangers  of,  36. 


i.\i>iox.  145 

Jj.v  inpliaiif^ilis,  7li,  71. 
septic,  7.'i. 

.simple,  isolated,  74. 
Ireatineiit,,  74. 

Marcy,  preparatioji  of  lcfiiif>arno  tondoii  hy.  8. 

stitch  of,  siibciiticiilar,  IG. 
Mediastiiuini,  penetrating'  wounds  of,  Ht>. 
Mici'ohic,  iiirectloii,  poisoned  wounds,  70. 
Micrococci,  J. 
Mitchell,  Weir,  70. 
Moist  dressings,  lOl. 

antiseptic,  in  cellulo-ciitaneous  erysipelas,  85,  86. 
in  int'eetions  intlanunations,  2i. 
in  frost  bite,  130. 
Morris,  Hobert  T.,  iise  of  ergot  and  vvariu  water  on  infected 
burns,  ]2r). 

Nails,   infiainniations  around   and    under,   in   post-mortem   in- 
fection, 72,  73. 

Nasal  cavity,  infection  from,  in  pnnctui'ed   wounds  of  brain, 
35. 

Nephrectomy,  53,  118. 

Nerve  or  nerves,  27. 

trunks,  sewing  of,  in  accidental  wounds,  26. 

Nurses,  precautions  against  carrying  infection  by,  85. 

Ointment,  boracic  acid,  23. 
Omentum,  rupture  of  great,  4S,  49. 
Open  drainage  for  disinfection,  24. 
Operations  on  infected  tissues,  22. 

in  private  dwellings,  11,  12. 

outfit  for,  11. 
Opei'ative  wounds,  14,  16. 
Opium,  use  of,  in  infection,  25. 

in  sliock,  28. 

Paget,   49,    71. 

Pasteur's  treatment  after  bites  by  rabid  animals,  79. 

Pei'itoneal,  cavity,  50. 

intra,  I'upture,  50. 

extra,  rent,  50. 

intra,  hemorrhage,  52. 

retro,  rupture  of  kidney,  52. 

intra,  rupture  of  bladder,  53,  54. 

extra,  rupture  of  bladder,  54. 

combined    treatment    of    intra    and     extra,     rupture     of 
bladder,  53,  54. 
Peritoneum.  47. 
Peritonitis,  46,  48. 
Pharynx,  burns  of.  by  cliemicals,  carbolic  acid.  127. 

use  of  alcohol  in,  127. 
Phlegmonous  erysipelas.  S3. 

treatment  of,  S3.  84, 
Pitcher,  115. 
Plaster  of  Paris  splints,  lOS. 

use  of.  in  compound  fractures.  lOS. 


14G  iMii;.\. 

I'oisonetl  wuiimls,  70. 
roisuiiini*.  c'iubdlii-  aoid,   121. 
Post-mortfin.  t'x:iininat  it)n,   is 

woiimls,  TO. 

l)oisonin{jr,  types  of,  71. 

tri>atnuMit  of,  loL-al  infection  in,  72. 

\\oun(ls    con.stitutional  I'lloots  of,  73. 
J 'oil  It  ices,   120. 
Pyemia,  peculiar  features  of,  Wi. 

symptoms  of,  '.K),  1)7. 

I'li-almont  of,  1)7,   100. 

delirium  of,  OS. 

chronic,  '.»•). 

complicated  by  septic  phlebitis,   10J. 

Quinine,  use  of,  in  septicemia.  09.  102. 

Kectum,    admiiiisti-at  ion    of    uoiirisliincnt    and    water    per.    in 

pyemia,  102. 
Kesection  of  arteries  and  veins  caused  by  bullets.  J12. 
JUibber  gloves,  106,  107. 
use  of,  132.  133,  134. 
Rupture  of  spleen  and  liver,  diagnosis  of,   l"). 
of  kidney,  45,  46. 
of  stomach  and  intestines,  48. 
retro-peritoneal,   of  intestines,  40. 
of  bladder,  40. 

intra-  and  extra-peritoneal,  50.  51,  53. 
retro-peritoneal,  of  kidney,  52. 
of  kidnej',  53. 

treatment  of,  53. 

Scalp,  wounds,  64. 

incised,  treatment  of,  04. 

contusions  of,  66. 

swelling-s  inider,  in  new  born  babes,  67. 

shavinpr  of,  in  fracture  of  skull,  68. 

erysipelas  of,  84. 

])reparation  of,  in  gunshot  wounds,  113. 
Senn,  use  of  hydrogen  gas.  41. 

test  for  ruptured  kidney,  49. 
Sepsis,  development  of,  after  retro-peritoneal   rupture  of  the 

kidnej',  53. 
Sej)tic  empyema,  secondary.  36. 

inflammation,  scalp  wounds,  65. 

peritonitis,  70. 

lymphangitis,  73. 

blood  poisoning.  93. 
treatment  of.  03. 
Sei)ticemia,  unusual  form  of,  sapremia,  03. 
Serpent  bites,  75. 
Shock,  after  accidents,  27,  28. 

treatment  of,  28. 

stimulants  in,  29. 

in  penetrating  wounds  of  chest,  37. 

symptoms  of,  46,  51. 


INDKX.  147 

tihoiik—foiirliKlrd. 

reaction  i'l-om,   I  10. 
treatnieiil  oF,  in  hiii-ns,  I'll. 
Silkworm  giit,  D. 

for  i)i1x'iT(i|j(('(l  slilclu^s,  !.">. 
Silver  wii't',  .sl(!riiizatioii  ol',  <>. 
Slvin,  wounds,  G4. 
grafting-,  65. 

in  burns,  126. 
disc'oioratioii  oi',  in  erysipelas,  83. 
siong-hing  of,  in  erysipelas,  85. 
disinfection  of,  13. 
Skull,  65. 

fracture  of,  in  contusions  of  scalp,  GT. 
compound  fractures  of,  vault,  67,  65. 
depressed  fracture  of,  68. 

treatment  of,  68. 
wounds  of,  gunsihot,  112,  113. 
Specilic  wound  infections,  erysipelas,  80. 
Spleen,  rupture  of,  45. 
Splints,  use  of,  in  contused  and  lacerated  wounds,  30. 

plaster  of  Paris,  in  compound  fractures.  108. 
Spong'es,  preparation  for  use,  11. 
Sj)rains,  cause  of,  55. 
treatment  of,  56. 
Sterilizers,  10. 
Stimulants,  heart,  63. 
in  erj'sipelas,  86. 
Stings  of  insects,  74,  75. 
Stitches,  19,  94. 

removal  of,  in  scalp  wounds,  64. 
catgut,  15. 

interrupted  or  continuous,  15. 
subcuticular,  in  wounds  of  face  and  neck.  16. 
and  their  extraction,  20. 
Stomach,  rupture  of,  48. 

washing  out  of,  after  carbolic  acid  poisoning,  128. 
Strychnia  as  a  stimulant,  29. 
Sunburns,  123. 

Suppuration,  in  post-mortem  poisoning  of  hands  and  nails,  73. 
of  glands,  74. 
streptococcus  of,  81. 
in  erysipelas,  82. 
Suturing,  65. 

of  llaps,  scalp  wounds,  65. 
wounds,  15. 

buried,  in  deep  wounds,  16. 
tension,  16. 

materials,  sterilization  of,  6. 
Symptoms  of  hemoi'rhage  in  penetrating  wounds  of  chest.  37. 
of  shock,  46,  51. 
of  joint  wounds,  60. 
of  erysipelas,  82. 
constitutional,  in  erysipelas,  84. 
of  pyemia,  96. 


148  INDIOX. 

Teclmiqiie,  proparatt)r,\ ,  siirgk-iil,  ;">. 

in  iiioisetl  ami  punctured  wounds,  4-1. 
Tendons,  kangaroo,  S. 

useof.  in  radical  cure  of  hernia.  3. 

prcjKiration  of,  8. 

injuries  of,  in  sj)rains,  oG. 
Tetanus,  87. 

characteristics  of,  87. 

bacillu.s,  2.  87. 

clinical  history  of,  S9. 

head,  90. 

oiaf;n()sis  of,  IM). 

acute,  '.»1. 

prognosis  in,  '.»1. 

treatment  of,  Dl. 
'I'liierscli's  method  of  skin  grafting,  120. 
'i'oiirniquet,  Ksmarch,  li'J. 

elastic,  28. 

Ureter,  blockii^g  of,  in  rupture  of  kidn(  y,  47. 

removal  of,  47. 
I'l'ine,  extravasation  of,  45. 

bloody,  4G,  47,  50. 

blood. in,  in  rupture  of  kidney,  47. 

Vault,  skull,  compound  fracture  of,  67,  OS. 
Veins,  resection  of,  112. 

Viscei-a,  abdominal,  involvement  of.  after  penetrating  wounds 
of  abdomen,  41. 
laparotomy-  for  gunshot  wounds  of,  4o. 
Aolkmann  sharji  spoon,  use  of,  in  pyemia,  101. 

Warts,  "Dissecting  porter's,"  72. 

a  type  of  post-mortem  poisoning,  71. 
location  of,  72. 
Wounds,  bacteria  and,  1. 

effect  of  bacteria  upon  healing  of,  1. 
inflammation  of,  caused  by  bacteria,  ".'. 
operative  and  accidental,  14. 
irrigation  and  cleansing  of  fresh,   14. 
suturing,  15. 

non-suppurating,  dressing  of,  17. 
aseptic,  supposedly,  behavior  of,  17,   18. 

treatment  of  infection  of,  19. 
made  into  infected  tissues,  22. 
accidental,  26. 
lacerated,  27. 

contused  and  lacerated,  29. 
punctured,  31. 

of  hands  and  feet,  31,  32. 

of  brain,  33. 

treatment  of,  33,  34. 
penetrating,  36. 

of  chest,  3G. 

treatment  of,  3^" 


liNDKX.  II!) 


Won  lids — coiK-liiilfd. 

of  pericardii! Ill  imd  liciiil,  .'J?,  .'JS,  ;;'.). 
iric'isod  and  |)iinc1  ined,  oJ'  abdomen,  40. 

tiTaliiicnf   of,  40,  41,  42,  4'-',. 
oi"  joints,  55. 

classilication  of,  55. 

compound,  59. 

of  upper  extroniitics,  '>'.). 

])iMictvired,  (i2. 

treatment  of,  02. 
of  scalp,  64. 
incised,  64. 
poisoned,  70. 
post-iTiorteni  or  dissection,  70. 

treatment  of,  72. 

constitutional  ett'ects  of.  7:!. 
specific  infection  of,  80. 

tetainus,  a  result  of,  87. 
gunshot,  112. 

of  skull,  112. 

of  chest,  114. 

of  abdomen,  114. 

Involving  bones  and  joints,  114.  115. 

of  kidney  and  liver,  117. 
treatment  of,  117,  IIS. 


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